Long-pulsed nd: YAG laser treatment of nail psoriasis: clinical and ultrasonographic assessment.

Nail psoriasis is a chronic, inflammatory condition which is difficult to treat, linked with greater psoriasis severity, and may be associated with anxiety and significant functional impairment of the quality of life. The 1064 nm Nd: YAG laser was reported to yield satisfactory results in the treatment of nail psoriasis.The aim of the study was to assess the clinical and ultrasonographic efficacy of long-pulsed 1064 nm Nd: YAG laser in the treatment of fingernail psoriasis and compare its effect to control fingernails.This intra-patient randomized controlled trial analyzed 86 fingernails collected from 13 patients suffering from cutaneous and nail psoriasis. The nails were randomized into two groups. Group A was treated with Nd: YAG laser once monthly for three sessions while group B served as control. Assessment took place at baseline, 1 and 3 months after the last treatment session. For scoring, the 32-points target NAPSI scoring systems was used. Additionally, two blinded dermatologists' score of improvement, patients' pain assessment by visual analogue score and ultrasonographic assessment were all performed.At the end of follow up, the medians of tNAPSI score, plate definition, matrix thickness, bed thickness and bed vascularity decreased significantly in the Nd: YAG laser treated group in comparison to baseline (p = 0.001, 0.006, 0.039, < 0.001 and 0.010, respectively). While, there was a non-significant reduction in median tNAPSI score in the control group at last follow up, however, ultrasonography recorded a significant reduction in the medians of plate definition, bed thickness and vascularity (p = 0.002, 0.011 and 0.033, respectively) from the baseline. Comparison of the Nd: YAG laser and the control groups showed no significant difference from baseline regarding the medians of tNAPSI, tNAPSI percentile improvement, pits count, blinded evaluation of photographs and ultrasonographic assessments.In conclusion, Nd: YAG laser showed clinical and ultrasonographic improvement in fingernail psoriasis. Ultrasonography is a useful noninvasive tool in diagnosing and monitoring the clinical and even the subclinical changes in nail psoriasis. Nail psoriasis although difficult to treat, may show spontaneous improvement.

A survey of the treatment and management of ingrown toenails by UK podiatrists: A cross-sectional survey.

BACKGROUND: Ingrown toenails are a common pathology. Although a range of conservative and surgical measures are widely used for this condition, little is known about their use in practice. This study explored current practice relating to the treatment or management of ingrown toenails by podiatrists in the UK. METHODS: A cross-sectional online survey (Qualtrics, Provo, UT, USA) conducted between March to June 2020 was distributed to practicing podiatrists treating or managing ingrown toenails in the UK. RESULTS: A total of 396 practicing podiatrists responded (60.1% based in the private sector). The majority (88.6%) performed nail surgery most commonly (54.3%) less than five a month. Nearly all (95%) only performed nail avulsion with or without chemical matrixectomy, universally using phenol (97.2%). Application time and number of applications varied but was most commonly applied three times (61.5%) for a total of 3 minutes (75%). Aftercare varied considerably between public and private sectors, with public sectors offering fewer follow-up appointments. CONCLUSIONS: Although there is a variation in clinical practice throughout the treatment pathway, almost all respondents offered nail avulsion with phenol matrixectomy, whereas very few provided incisional nail surgery. This data provides the most comprehensive description of how UK podiatrists conduct nail surgery for onychocryptosis.

Nail bed trauma reconstruction and artificial nail replacement - a case report.

Nail bed reconstruction is crucial after fingertip trauma, impacting both function and aesthetics. In this article, the authors describe a case of partial distal phalanx amputation of the index finger with laceration of the nail bed's remaining part. A traumatically elevated skin-fat flap covered the exposed bone on the fingertip, preserving finger length and sensitivity on the radial side. A full-thickness skin graft from the forearm closed a secondary defect on the finger pulp. Nail bed suturing prevented scarring and nail deformity, and a temporary artificial plastic nail replacement maintained the nail bed's shape. Temporary artificial nail replacements protect the regenerating fingertip bed, promote healing, and prevent nail deformities. Proper adaptation of lacerated nail bed edges, supported by either the patient's own nail or a temporary artificial nail, is crucial for optimal fingertip restoration, including proper nail shape.

[Emmert's plastic surgery]. / Emmert-Plastik.

OBJECTIVE: The aim of the surgical intervention is the elimination of infections, ulceration and pain caused by ingrown nails (unguis incarnatus). INDICATIONS: A surgical intervention is recommended for ingrown nails (the large toenail is most frequently affected) in stage III and higher (according to the Mozena classification) as well as in cases of nail plate defects and recurrences. CONTRAINDICATIONS: In cases where a disturbance of wound healing is expected and general contraindications for surgery. SURGICAL TECHNIQUE: The surgical approach incorporates a half-moon-shaped skin incision and a straight longitudinal nail incision. Both incisions extend to the bone. A wedge-shaped piece of tissue is removed and after thorough curettage and rinsing the wound is closed using transungual single-button sutures. POSTOPERATIVE MANAGEMENT: Regular changes of wound dressing, relief of the affected ray by immobilization during wound healing. An antibiotic therapy is only indicated in selected cases. RESULTS: Between 1 January 2013 and 1 January 2023 a total of 50 Emmert's plastic surgery operations (15 women and 35 men) were performed at the Klinikum Vest, Knappschaftskrankenhaus Recklinghausen. The average age of the patients was 50.6 years. The mean follow-up time was 63 months. The outcome and satisfaction of the patients were evaluated according to the self-reported foot and ankle score (SEFAS). The total point count (median value) of the evaluated SEFAS score was 44.

Fingertip injuries and their reconstruction, focusing on nails.

The fingertip is a complex anatomical structure that is frequently injured, especially in manual workers. Different classifications have been reported, considering injury orientation, level and geometry. To optimize treatment planning, the area of soft-tissue defect should be considered. Treatment aims to conserve as long a finger as possible, restore sensation (S3 + or more) and ensure a pleasant esthetic appearance. When amputation occurs, the best treatment is replantation when conditions allow. When this is not possible, the fingertip should be used as a composite graft or the nail complex can be grafted and soft tissue reconstructed, according to the preferred method. In defect without amputation or if the distal part of the finger is not present or not useful, many reconstructive techniques have been described. Depending on the injury, patient characteristics and requirements and the surgeon's skills and experience, the treatments vary from secondary healing to free flaps. In this paper, the various treatment options are described and discussed. Nowadays, considering most variables, the best treatment in fingertip injury is secondary healing with occlusive or non-occlusive dressing, even in case of bone exposure. This simple solution is able to restore a nearly normal fingertip with good sensation without further injuring the hand.

Microsurgical reconstruction of the nail.

Very often, post-traumatic defects involve multiple tissues. Microsurgical techniques can reconstruct them with tissues taken from a toe: from the nail complex alone to compound osteo-onychocutaneous flaps. Several techniques have been reported since the 1980s. This paper describes techniques and indications for microsurgical nail reconstruction. Technique differs according to the deficit, and first and foremost whether only the nail complex is involved or whether other components of the fingertip important for the normal growth of the nail, such as the phalanx bone or the finger pad, are also missing (toenail flaps and the custom-made osteo-onychocutaneous flaps). For most patients the absence of a fingernail is an esthetic rather than functional concern, and the outcomes of microsurgical reconstruction are far from ideal in this regard. We prefer to reserve reconstruction for symptomatic patients with functional impairment.

Nail-preserving excision of glomus tumor in the second toe: Case report and literature review.

INTRODUCTION: This case report describes the diagnosis of a glomus tumor in the second toe of a 38-year-old female, followed by surgical treatment utilizing a transungual approach to preserve the nail. This study highlights the diagnostic challenges and surgical strategies to treat such tumors while preserving nail integrity. PATIENT CONCERNS: Pain occurred once a week, but over time, it increased, and just before seeking medical attention, she experienced pain more than 5 times a day. The pain worsened when cold water touched her toe. DIAGNOSIS: We observed a slight hump indicating nail plate deformity, and the patient exhibited severe pinpoint tenderness (positive Love test) in the affected area. Color duplex ultrasound was performed for further investigation, revealing a hypervascular hypoechoic nodule measuring 0.5 cm in size at the nail bed of the right second toe. INTERVENTION: The surgery was performed under digital nerve block anesthesia using a modified transungual nail-preserving approach for the excision of the glomus tumor. OUTCOMES: The pain that was reported prior to the surgery has improved postoperatively, and the recovery has been uneventful without any other complication. CONCLUSION: This paper provides a comprehensive examination of a rare glomus tumor in the second toe, elucidating both diagnostic intricacies and treatment modalities. It emphasizes the dual necessity of achieving total tumor excision while also considering aesthetic outcomes. The insights presented herein are intended to serve as valuable guidance for clinicians confronted with similar clinical scenarios, underlining the delicate interplay between effective tumor management and the preservation of cosmetic integrity.

Techniques of nail anesthesia.

Nail anesthesia is systematic in nail surgery. It is usually performed by the surgeon, a few minutes ahead of the procedure. Several techniques and substances are available. The rules of anesthesia must be respected for surgery to be comfortable, with the whole operated zone anesthetized. The surgeon has to select appropriate type of anesthesia according to the surgical indication, patient age and comorbidities; the local anesthetic must be chosen; contraindications must be respected; the injection site must be selected; the quantity must be determined; and the patient must be monitored for any complications. All these steps are mandatory, before, during and after nail anesthesia, for nail surgery to be painless and safe.

Nail dystrophy for the surgeon.

Injuries to the fingertips are the most frequently occurring damage to the hand. The nail is an exceptional structure within the human body that offers both stability and protection, as well as the ability to perform fine and precise movements. Nail dystrophies are numerous, post-traumatic, post-infection or even degenerative. They raise many difficulties for the treating hand surgeon. Which anatomical structure is dystrophic? Is there any secondary fungal superinfection to be treated before surgery? Among the various techniques proposed, which one will help to improve my patient as a complete cure is rarer than partial failures. In this chapter we have chosen to describe the surgical techniques, their difficulties and drawbacks, that are available for the most frequent dystrophies that the hand surgeons may treat.

Ingrown Toenails: A Survey Among Dermatologists on Current Treatments.

BACKGROUND: To date, there is no formal consensus on how to treat ingrown toenails. Despite the risk of causing irreparable damage to the nail, highly invasive procedures are still common. Less-invasive, matrix-directed techniques with shorter downtime and high cure rates exist, but, perhaps because of a lack of awareness, appear not to have been universally adopted. OBJECTIVE: The authors' study sought to generate data on common practices in the treatment of ingrown toenails. MATERIALS AND METHODS: The authors developed and conducted an online survey to ask dermatologists/dermatosurgeons how they would proceed in 9 different cases of ingrown toenails based on photographs. RESULTS: The authors received 154 replies. Nonsurgical interventions, including advice on nail care/foot baths/ointments/wraps/padding, were always the most frequently chosen option. Removal of the lateral nail plate followed by chemical partial matricectomy (phenolization) was the most or second-most frequently chosen surgical intervention. The answers were highly heterogeneous, and there was no unanimity based on morphology alone. CONCLUSION: Except for a preference for nonsurgical interventions, the authors could not identify any clear treatment standards. The heterogeneity of treatment approaches suggests the need for a guideline.

Surgical interventions for ingrown toenail.

BACKGROUND: Paronychia is a prevalent clinical disease affecting the soft tissue surrounding the nails. Most cases of toenail paronychia are commonly associated with ingrown toenails. While conservative treatment is effective for mild cases of ingrown toenails, surgical intervention becomes necessary for moderate to severe cases, particularly when granulomas form. OBJECTIVE: To provide a systematic understanding of these classic and modified procedures for surgeons to select the appropriate surgical interventions for patients suffering from moderate to severe ingrown toenails and discuss this technology's advantages and limitations for dermatologic surgery. METHODS: A literature search was performed using PubMed/MEDLINE and Google Scholar databases. Studies discussing surgical intervention for ingrown toenails were included. Moreover, the surgical steps were meticulously depicted by detailed schematic diagrams. RESULTS: These surgical techniques can be divided into three categories: matrix resection, debulking of periungual soft tissues, and the rotational flap technique. Each approach possesses distinct advantages and limitations. CONCLUSION: For moderate to severe cases, surgical interventions may exhibit superior outcomes, faster recovery times, and lower recurrence rates. The surgeon must possess a comprehensive understanding and proficient skillset in various surgical techniques for ingrown toenails.

Complications in nail surgery and how to avoid them.

Complications in nail surgery are not that frequent. Apart from complications that are common to every hand procedure, intense pain is the major issue with nail surgery. To prevent complications, good knowledge of anatomy and physiology is required to avoid misdiagnosis or inappropriate technique. However, some complications, such as postoperative nail dystrophy, are unavoidable, and must be known and discussed with the patient prior to the procedure in order to prevent disappointment that may lead to medico-legal cases. This paper will discuss the most frequent complications encountered.

Surgical anatomy of the nail.

Knowledge of nail anatomy is a prerequisite for both diagnostic and therapeutic purposes. The nail apparatus is a highly specialized structure, but is in close relationship to the distal phalanx which supports it and to the pulp which carries the sensory receptors and is involved in pinching. It can be divided by the nail plate into the perionychium underneath, and the paronychium above. The perionychium includes, from proximal to distal: the nail matrix, the sole structure responsible for the growth of the nail plate; the nail bed, mostly responsible for adhesion of the plate; and the hyponychium, which is the most distal part, where the nail plate loses its adhesion. The paronychium comprises three nail folds, one proximal and two lateral, that embed the nail plate. The nail apparatus is richly vascularized, with three main sources, and richly innervated, which explains why trauma and surgery are so painful.

Successful treatment of onychomatricoma with minimally invasive surgical procedures based on its pathogenesis: A case report.

Onychomatricoma is a rare, fibroepithelial tumor of the nail. Although it is benign, unnecessary and excessive treatment, such as extensive or total removal of the nail matrix, has been reported in the past. Recently, it was speculated that onychomatricoma is derived from onychomatricodermis, the dermal stroma of the nail matrix. Excision of the stromal rather than the epithelial component of the tumor is important. However, since the boundary between the normal and diseased stroma is usually unclear, minimal excision at the base of the tumor projection should be sufficient. We report a case of onychomatricoma and suggest a method of surgical treatment that would minimize postoperative deformity of the nail plate.

Huge hypertrophic scar secondary to chronic ingrown toe nail mimicking tumor: A case report.

RATIONALE: A huge hypertrophic scar formation secondary to chronic ingrown toe nail mimicking tumor is a rare disease. It is not only causing concerns cosmetically, but also hindering normal daily activities physically and socially. In this paper, we present an unusual case of bilateral ingrown nails with different phases. One resulted in a large hypertrophic scar caused by stimulation from secondary to chronic ingrown nail. PATIENT CONCERNS AND DIAGNOSIS: A 44-year-old man with a huge mass (7 × 4 × 8.5 cm) in his right great toe and inflamed ingrown nail in his left great toe visited the clinic. The mass in the right toe showed an irregular and bizarre shape with a stellate ulcer (2 × 2 cm) at the distal end. After removing an ingrown nail 3 years ago with minor repetitive trauma, self-managed wound has grown into a tumor-like mass, resulting in intolerable discomfort. In gross appearance, a stalk appeared to originate from the lateral side of the nail bed with the ingrown nail in the great toe showing inflamed medial and lateral gutter and causing redness and tenderness. Huge hypertrophic scar formation secondary to chronic ingrown toe nail mimicking tumor is a rare disease that is not only causing a cosmetic concern, but also hindering normal daily activities physically and socially. INTERVENTION AND OUTCOMES: Excisional biopsy was performed for both great toes. Biopsy confirmed chronic ulcerative inflammation with a hypertrophic scar. The resection site healed and persisted well at 12 months after surgery. CONCLUSION: Our unusual case suggests that the natural course of an untreated ingrown toe nail may result in hypertrophic scar extending far to mimic tumorous conditions.

Combined Great Toe Dorsal Nail-Skin Flap and Medial Plantar Flap for Reconstruction of Degloved Finger Loss.

BACKGROUND: Historically, the degloved finger with the total loss of nails and skin has been resurfaced in two stages. Furthermore, proximal finger amputation requires an additional bone-tendon graft and an expanded great toe wraparound flap transfer for better outcomes. This article recommends a novel strategy to address these problems in a single stage using a dorsal nail-skin flap and medial plantar artery perforator flap. METHODS: From March of 2015 to June of 2018, nine procedures were performed to resurface with skin loss to the metacarpophalangeal joint level, and three amputated fingers were reconstructed with an extra bone-joint-tendon graft simultaneously. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. A standardized assessment of outcome in terms of sensory, functional, and aesthetic performance was completed. RESULTS: All flaps survived. The contour and length of the reconstructed digits were comparable with the contralateral finger. The mean static two-point discrimination was 11.0 mm (range, 9.0 to 14.0 mm). The average score of the Disabilities of the Arm, Shoulder, and Hand questionnaire and Michigan Hand Outcomes Questionnaire were 2.5 (range, 0 to 5) and 90.1 (range, 82 to 96), respectively. The mean Foot and Ankle Disability Index score was 95.6 (range, 93 to 99). At the last follow-up, the functional and aesthetic outcomes, and the restored sensation, were satisfactory for all fingers. CONCLUSION: This strategy may provide an alternative for selected patients seeking cosmetic resurfacing and functional reconstruction, preserving a weight-bearing plantar area with less morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.