Treatment Pearls
1. Hard and brittle nails - add moisture
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Treatment Pearls
19.1 Brittle Nails 1. Hard and brittle nails – add moisture 2. Mildly affected nails – Aquaphor or 10–20% urea twice a day 3. Very dry nails: (a) Urea (30–50%) in the morning (b) Aquaphor at bedtime – one may also soak the digits at bedtime, apply Aquaphor then light white cotton gloves 4. Soft and brittle nails – too much moisture, use a conditioning cream with 5 to 12% lactic acid, olive oil, SBR Lipocream®, or Impruve® cream twice a day. For hard and brittle or soft and brittle nails: (a) One multivitamin a day (b) Biotin 2.5–5 mg once a day (c) Light cotton gloves under vinyl gloves for wet work (Allerderm®). Heavy cotton gloves for dry work. For medical personnel, disposable, non powder vinyl gloves for work (d) Strict contact irritant avoidance regimen (e) Mild soap like Dove® (f ) Avoid i. Frequent unnecessary hand washing ii. Frequent application and removal of nail cosmetics iii. Artificial nails
19.2 Darier’s Disease 1. Keep the nails short 2. Treat any secondary infection 3. Strict irritant avoidance regimen 4. The Koebner phenomenon is important 5. Specific treatments are generally anecdotal and unproven (a) Steroids i. Topical high potency twice a day for 1–2 weeks ii. Intralesional triamcinolone acetonide 3–5 mg/ml strength – inject once a month for up to 4 months iii. Occasional systemic steroids – begin with 70 mg all in one dose in the morning and taper 5 mg a day (b) Retinoids i. Topically once a day. Stop if it is too irritating or if it is not better in 1–2 months ii. Isotretinoin or acetretin in low dose for up to 6 months
A. Tosti et al., Color Atlas of Nails, DOI: 10.1007/978-3-540-79050-1_19, © Springer-Verlag Berlin Heidelberg 2010
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19 Treatment Pearls
19.3 Dystrophic Fifth Toenail 1. Keep the nail short. 2. Apply 20–30% urea 1–2 times a day to soften if too thick to cut. 3. If you are treating onychomycosis, it is important to tell the patient in advance if there is coincident dystrophic fifth toenail that the fungus treatment might resolve the infection but the dystrophic appearance is likely to remain. 4. Matricectomy may be used for a permanent solution.
19.4 Green Nails If there is no pain, swelling, or pus, usually no oral therapy is needed. 1. Keep nails short and use a strict irritant/moisture avoidance regimen (see onycholysis) 2. Gentamicin drops can be applied twice a day 3. Drops of vinegar can be applied twice a day
19.5 Ingrown Toenails 1. Remember that the ingrown nail spicule is like a foreign body. 2. For early ingrown nails (non infected): (a) Soaks: one teaspoon salt in one pint of cold water for 5 min, then apply 20% urea cream to the nail plate then a mid/high potency topical steroid to the inflamed nail fold. Do this 2–3 times a day for 7–10 d. (b) One may gently introduce a wisp of cotton under the most lateral part of the ingrown nail plate. (c) One may try to gently lift out the ingrown nail plate with dental floss. 3. For more advanced ingrown nails: (a) If culture is infected, then empirically treat with cephalexin 500 mg
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