Painful nails: A practical approach to the diagnosis and management of painful nail conditions.

Because several nail disorders share similar clinical features, their diagnosis and management can be challenging to clinicians. The physical examination may disclose localized abnormalities or point to an underlying systemic disease, requiring additional workup. Furthermore, cosmetic distress and nail-related symptoms (e.g., tingling, stinging, numbness, and pain) are common factors that influence the patient's search for medical assistance. Nail pain (i.e., onychalgia) can accompany both localized and systemic pathology. Onychalgia can be acute or chronic according to the time of evolution; patients may describe it as intermittent or constant, and as a throbbing, burning, sharp, or shooting sensation denoting the nature of the pain. It may be exacerbated by colder temperatures, touch, and increased activity (e.g., manipulating objects, walking). We present four main groups of conditions that might cause nail pain: nail tumors, nail deformities, inflammatory or infectious diseases, and external or traumatic agents. Our article includes an overview of the clinical features, as well as diagnosis and management pearls for each entity. Physicians (dermatologists and nondermatologists) should be aware that abnormalities of the ungual and subungual space are not exclusive of dermatological disorders but may also be present in noncutaneous contexts.

Congenital malalignment of the great toenail: Conservative and definitive treatment.

Congenital malalignment of the great toenail, or ungual malalignment, is a rarely recognized disorder. It is characterized by lateral deviation of the longitudinal axis of the nail plate with respect to the distal phalanx, and if untreated, complications in the late teens and adulthood may arise. In this study, we have reviewed conservative and definitive treatments for this disorder.

Pincer Nail Deformity: Clinical Characteristics, Causes, and Managements.

A pincer nail is a common nail deformity of toenails and is characterized by nail thickening and nail plate deformation. It often causes severe pain for patients. We perform a thorough literature review and an additional review of pertinent clinical cases, aiming to provide a comprehensive review of the etiology, pathogenesis, clinical classification, differential diagnosis, and treatment of pincer nail deformity (PND). Understanding the clinical characteristics and treatment progress of a pincer nail will provide clinicians with comprehensive and evidence-based information about PND, thus allowing the selection of an appropriate treatment according to the patient's request and the clinical manifestations of PND, which should maximize patient satisfaction.

Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice.

Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.

A Review of Nail Dystrophies for the Practitioner.

GENERAL PURPOSE: To provide information about nail pathology from its clinical presentation, pathophysiologic origin, clinical diagnosis, diagnostic testing, and treatment. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, NPs, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Review the etiology of and risk factors for the various types of nail pathology.2. Describe the clinical manifestations, diagnosis, and treatment of the various types of nail pathology. ABSTRACT: Nail pathology has a range of etiologies, from biomechanical trauma to systemic associations. Within this review, nail pathology is examined from a clinical presentation, pathophysiologic origin, clinical diagnosis, diagnostic testing, and treatment standpoint. Nail dystrophy reveals both systemic and exogenous pathology, reinforcing the value of assessing nails during the medical examination.

Nail pathology has a range of etiologies, from biomechanical trauma to systemic associations. Within this review, nail pathology is examined from a clinical presentation, pathophysiologic origin, clinical diagnosis, diagnostic testing, and treatment standpoint. Nail dystrophy reveals both systemic and exogenous pathology, reinforcing the value of assessing nails during the medical examination.

Factors Influencing the Treatment Effect of Superelastic Wire Orthonyxia for Nail Plate Deformity.

BACKGROUND: Orthonyxia is an effective, noninvasive treatment for transverse nail curvature deformity. OBJECTIVE: To discover the factors influencing treatment results of superelastic wire orthonyxia (SEWO). MATERIAL AND METHODS: A retrospective study was conducted using clinical records of patients treated with SEWO. A multiple linear regression model was used to explain the correlation between correction pace (% per week) and the other collected variables (patient age, sex, position of treated toe, wire diameter [WD, mm], wire residence time [WRT, weeks], nail plate thickness [PT, mm], baseline nail curvature index [NCI], number of previous treatments, and the correction pace of previous treatments [CPT, % per week]). A logistic regression model was used to identify risk factors for adverse effects. RESULTS: A total of 475 cases were collected from 197 patients. The correction pace was positively related to baseline NCI, WD, and correction pace in previous treatment. Also, it was negatively related to WRT and nail PT. No clinical factor was correlated with the occurrence of side effects. CONCLUSION: The correction pace of SEWO is affected by the baseline NCI, the diameter of the wire, nail PT, the CPT, and the WRT.

Late-onset malalignment of the great toenails.

Great toenail malalignment is characterised by lateral deviation of the longitudinal axis of the nail plate with respect to the hallux, and is usually post-traumatic, iatrogenic or due to congenital malalignment of the great toenails. We present cases of great toenail malalignment with onset in adolescence or young adulthood without preceding nail surgery or acute trauma. We postulate that this may represent a late-onset presentation of congenital malalignment of the great toenails.

Improvements in lower-limb muscle strength and foot pressure distribution with foot care in frail elderly adults: a randomized controlled trial from Japan.

BACKGROUND: Abnormalities in the feet and toenails are common among the elderly and may increase the risk of falls. This study aimed to investigate the changes in toe-gap force, knee-gap force, foot pressure distribution, the ability to perform activities of daily living, subjects' feelings and behaviors, and physical function resulting from daily lifestyle modification and foot care. METHODS: The study participants included 74 elderly adults (mean age 80.3 ± 7.5 years) with foot problems who had been divided into three groups based on Japan's nursing care insurance system levels: certified ineligible for support, eligible for support, or eligible for long-term care. Additionally, a control group of 106 elderly adults in good health was recruited. The differences between the intervention and control groups was examined using the Student's t-test, and differences between the three intervention subgroups and the control group were examined using one-way analysis of variance. RESULTS: After intervention, abnormalities in the participants' feet and toenails improved. Significant increases in lower-limb muscle strength were observed, and foot pressure distribution had improved. The foot-care intervention significantly improved lower-limb muscle strength and decreased the risk of falling, even in elderly adults whose physical function had deteriorated. CONCLUSION: In frail elderly adults, care of the feet and toenails can improve lower-limb muscle strength and foot pressure distribution. In addition, the individuals' social participation increased, and their behavior improved. TRIAL REGISTRATION: University hospital Medical Information Network- Clinical Trials (UMIN-CTR) with the number: UMIN000034742 . Registration date: 11/01/2018.

DOOR syndrome: A case report and its embryological basis.

DOOR syndrome is an extremely rare genetic disorder. "DOOR″ is an acronym to describe the combination of: deafness, onychodystrophy, osteodystrophy and mental retardation. We present a patient, with all of the above-mentioned main symptoms, that was rehabilitated with convencional hearing aids. The presented case suggested that every case of deafness and abnormal nails and phalanges in the hands and feet should have a clinical diagnosis of possible DOOR syndrome. Based on embryological process, congenital abnormal nails or phalanges highlights the importance for detailed hearing screening.

Triple Combination Therapy for Pincer Nail Deformity: Surgical Matricectomy, Thioglycolic Acid, and Anticonvex Sutures.

BACKGROUND: Pincer nail deformity (PND) is characterized by an excessive transverse curvature of the nail plate that increases along the longitudinal axis of the nail. Although many conservative and surgical techniques have been used in clinical practice, an established consensus for the correction of PND has not been present yet. OBJECTIVE: Aim of the technique described in this article is to provide to restore the suitable nail-matrix system curvature by a simplified and quick approach, which could be seen as a synthesis of conservative and surgical treatments described in the literature. MATERIALS AND METHODS: Nineteen cases of pincer nail of the great toe in 14 patients were analyzed. After softening nail plate with 5% thioglycolic acid solution for at least half an hour, surgical bilateral matricectomy and 2 anticonvex sutures with 1-0 polypropylene were performed to ensure proper nail plate shape. Besides demographic data, visual analog scale (VAS) score for pain, width index, height index, patient and surgeon satisfaction scores, operation time, and the day of painless return to the daily activities were investigated. RESULTS: A statistical significance was observed in VAS score for pain, width, and height indices between preoperative and postoperative values. CONCLUSION: This report gives acceptable outcomes with a combination of surgery and conservative treatments.

Median canaliform nail dystrophy treated with a 1064-nm quasi-long pulsed Nd:YAG laser.

Median canaliform nail dystrophy (MCND) is an uncommon and idiopathic dystrophic change, which typically appears as central, longitudinal groove or split involving one or both thumbnails. Various treatments including a potent topical steroid, an intralesional injection of triamcinolone 2.5-3 mg/dL, medications for systemic treatment, and topical psoralen plus ultraviolet A (PUVA) have been tried to treat the disease. However, each treatment has limitations including severe pain, inconsistent treatment results, long treatment periods, and dissatisfaction with effects of treatment. In recent years, 1064-nm Nd:YAG laser is used for skin rejuvenation by the effect of collagen synthesis and remodeling via induction of growth factor expression. Therefore, we tried 1064-nm Nd:YAG laser to treat this nail dystrophy. A 53-year-old man presented with median nail dystrophy on both thumbs for 3 years. The nail dystrophy was treated only with 1064-nm quasi-long pulsed Nd:YAG laser. He was offered 10 sessions of treatment, and the right thumbnail showed good response and the left thumbnail showed fair response. He experienced severe pain during the treatment (Numerical rating scale (NRS) 8) and was satisfied moderately with the results (NRS 6.5). We report a case of treatment of MCND with 1064-nm quasi-long pulsed Nd:YAG laser with excellent clinical improvement.

Congenital Malalignment of the Great Toenails With Acute Paronychia.

Congenital malalignment of the great toenails (CMGT) has been well documented. In the present case, it was complicated by acute paronychia. It is important for physicians to recognize and treat CMGT to prevent sequelae such as onychocryptosis, onychogryphosis, and recurrent paronychia.

Onychotillomania: An underrecognized disorder.

Onychotillomania is an uncommon and likely underreported condition in which patients repetitively manipulate the different constituents of the nail unit. Onychotillomania is characterized by a range of nonspecific findings, including bizarre morphology of the nail plate and damage to the nail bed and periungual skin. Histopathological changes are also nonspecific, but may be viewed as analogous to lichen simplex chronicus and prurigo nodularis of the skin. Clinical history is essential to making this diagnosis, as effective treatment modalities may focus on behavioral therapies and psychiatric medications.

Idiopathic 20-nail dystrophy.

Twenty-nail dystrophy is a rare disease, typically with all 20 nails affected, which normally occurs as an idiopathic condition in childhood but can be linked to other diseases. We report a case of a 7-year-old girl with a 3-year history of 20-nail dystrophy and no associated diseases or family history of skin or nail diseases. She was followed and treated conservatively and, after 6 years of follow-up, we found a marked improvement and almost full resolution of her nail dystrophy. The aim of this report is to show that idiopathic 20-nail dystrophy in children is a self-limiting condition and thus can be treated conservatively.