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10 Irritant Contact Dermatitis of the Nails

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10 Irritant Contact Dermatitis of the Nails 89 10 Irritant Contact Dermatitis of the Nails Patricia G. Engasser Contents ena) due to irritant reactions can subsequently lead to psoriasis or lichen planus of the nails. 10.1 Mechanical Irritation . 89 10.1.1 Recreational . 89 10.1.2 Occupational . 89 10.1 Mechanical Irritation 10.1.3 Cosmetic . 90 10.1.4 Miscellaneous . 90 10.1.1 Recreational 10.2 Physical Agents . 90 10.2.1 Irradiation . 90 10.2.2 Foreign Matter . 90 Splinter hemorrhages form when blood leaks from 10.2.3 Moisture . 90 the longitudinally oriented blood vessels of the nail 10.3 Chemical . 90 bed and on some occasions, are related to trauma. 10.3.1 Medicinal . 90 More noticeable are the subungual hematomas that 10.3.2 Occupational . 91 result from trauma. Athletes participating in sports 10.3.3 Cosmetics . 91 such as tennis or track, commonly develop hemato- 10.3.4 Miscellaneous . 91 mas below the toenails. 10.4 Biological . 92 Nail biting, tics, or habits of fiddling with nails at 10.5 Prevention and Therapy . 92 their base can cause injury to the matrix and produce References . 92 nail plate dystrophies [1]. Chronic trauma from faulty ambulatory biomechanics can result in nail plate hy- pertrophy, subungual corns, ingrown toenails, and onychogryphosis [2]. Some cases of longitudinal mel- Nails have served our species well since the dawn of anonychia form from footwear causing friction, but mankind, but fingernails are frequently traumatized frequently this diagnosis requires a biopsy to differen- functioning as tools. When man adopted closed shoes, tiate it from melanoma [3]. the toenails were exposed to a generally warmer, moister atmosphere. Though shoes protect the nails from some trauma, ill-fitting shapes also damage the 10.1.2 Occupational nail. Irritant environmental factors that cause nail damage may be categorized as mechanical, physical, Acute injury with a tool such as a hammer can cause chemical, and biologic. Frequently these factors act nail dystrophy and even permanent destruction, but together to irritate the nail unit. Four keratinizing this diagnosis is usually obvious. Nail dystrophy components of the nail unit are: posterior nail fold, caused by repeated minor trauma is frequently not nail matrix, nail bed, and hyponychium. Injuring any recognized. Distal onycholysis was reported in a component may result in change in appearance of the chicken-processor who plucked the chickens with his horny nail plate. Irritant hand dermatitis from any bare fingers [4]. Mushroom growers who lift heavy cause involving nail folds or fingertips may cause nail plastic bags also develop onycholysis frequently ac- changes. Isomorphic responses (Koebner phenom- companied by koilonychia, nail splitting, and splinter 90 Patricia G. Engasser hemorrhages [5]. Koilonychia attributed to trauma 10.2.2 Foreign Matter has been reported in toenails of rickshaw pullers [6], and fingernails in a pin threader [7], a coil winder [8], Barbers and hairdressers may have the skin of their and car mechanics [9]. Beau’s and Mees’ lines have fingertips or hyponychium invaded by small pieces of both been observed caused by trauma [10]. hair, and these foreign bodies cause onycholysis. Sim- ilar injury to the posterior nail fold causes paronychia to form. Onycholysis develops with penetration of 10.1.3 Cosmetic thorns, splinters, bristles, fibrous glass, and pieces of metal in other occupations [17]. Granulomatous Manicures may include removal of remnants of nail lesions and split nail deformities develop from pen- polish, shaping the nail plate, and pushing back cu- etrating wounds from sea urchin spines in fishermen ticle off the nail plate and/or clipping it. Rigorous at- and divers [18]. tacks on the cuticle with instruments can temporarily injure the distal nail matrix below resulting in leuk- onychia striata [11], and in some cases permanent 10.2.3 Moisture nail deformity [12]. Cuticle destruction leads to paro- nychia and nail plate dystrophy. Vigorously cleaning Immersion of the hands in liquid that leads to mac- debris and dirt below the distal free end of the nail eration of the skin of the posterior nail fold ultimately plate with sharp instruments injures the hyponych- predisposes to chronic paronychia. Many occupa- ium causing onycholysis. Nails that are buffed too vig- tions require immersion of the hands or conditions orously become transversely grooved [13]. which keeps the hands moist—custodians, cooks, kitchen helpers, health care workers, and housewives to name only a few. Invasion of the posterior nail fold 10.1.4 Miscellaneous by microorganisms can follow, leading to chronic in- flammation. Kern discusses the early occupational Challenges to the clinician’s acumen arise when nail diseases literature, which showed that immersion hemorrhages are noted in a seriously ill patient unable accompanied by mild trauma also leads to onycholy- to provide a history to designate the cause as trauma sis [19]. In 1931, in a ketchup bottling plant, work- rather than bacterial endocarditis. In a reported ex- ers who removed excess glue from bottles immersed ample, a neurologist’s maneuver of pushing the base in warm water by picking it off with their fingernails of the nail with a pen to prompt a pain response in developed onycholysis within 48 h. As with washer- a comatose patient resulted in puzzling subungual women, observed previously, the combination of wa- hematomas. An observant nurse’s history led the der- ter immersion and trauma led to nail changes. Irritant matologists to the correct conclusion about the trau- reactions of the nail often involve different combina- matic origin [14]. tions of mechanical, chemical, physical, and biologi- cal injuries. The role of hydration in the development of ony- 10.2 Physical Agents choschizia (lamellar dystrophy) has been studied ex- perimentally by soaking pieces of nail plate in liquid. 10.2.1 Irradiation Onychoschizia was produced by successive hydration and dehydration of these pieces of nail over 3 weeks The nail plate is rather resistant to ultraviolet light but not by hydration alone [20]. damage. However, patients who ingest photosensi- tizing drugs, such as the tetracyclines, followed by intense ultraviolet light A (UVA) exposure, develop 10.3 Chemical photo onycholysis. Inadvertent exposure to micro- wave radiation in two snack bar employees was impli- 10.3.1 Medicinal cated in the development of Beau’s lines [15]. Chronic, small, irregular, occupational X-ray exposure has Irritant concentrations of chemicals are used for ther- been noted to cause the nails to become brittle and apeutic purposes. By applying 40% urea paste under crack easily [16]. In the example of koilonychia in a occlusion to the nail plate, South and Farber refined pin threader sited above under mechanical injury, lo- a technique for nonsurgical avulsion of dystrophic cal heat was also involved in the working conditions toenails [21]. The paste is occluded for 7 days. Appli- and was a contributory factor [7]. cation of the dressings requires exquisite care so the 10 Irritant Contact Dermatitis of the Nails 91 skin folds surrounding the nail plate are protected file, and methacrylic acid is applied. MA nails adhere from this concentration of urea to prevent more ex- poorly and require more abrasion and nail plate thin- tensive irritation. This technique is particularly use- ning to adhere. MA nails are tougher and reportedly ful for elderly individuals who may be immunosup- transfer more traumatic forces to the natural nail pressed, diabetic, or anticoagulated. plate resulting in more frequent splitting of the nail Permanent destruction of the matrix of dystro- plate near the matrix [27]. Onycholysis and paro- phic toenails is a common therapeutic maneuver, nychia caused by allergic reactions to these methac- and partial matricectomy is used to treat recurring rylates usually occur after several months of this type ingrown toenails. Traditionally, matricectomy is per- of nail grooming, but there has been little recognition formed by applying 89% phenolic acid to the exposed of the nail thinning and irritant reactions that pre- matrix [22]. dispose to the development of allergy. A distressing adverse effect of sculptured nails has been paresthesia. Baran and Schibli reported permanent paresthesia in 10.3.2 Occupational a patient who did not have an allergic reaction to the monomer, suggesting that this was a direct effect on The most dramatic chemical irritant reactions of the nerves [28]. nail unit are caused by hydrofluoric acid. Hydro- During manicures, cuticle remover is applied to fluoric acid can etch glass and is used in foundries, the base of the nail to soften the cuticle by breaking glassworks, and in semiconductor manufacture. The the disulfide bonds of keratin, so that the cuticle can fluoride ion penetrates the skin freely interfering be pushed back or abraded. Cuticle removers fre- with calcium activity and causing deep tissue injury, quently contain sodium hydroxide, potassium hy- in some cases, without initial pain. Clinicians must droxide, inorganic salts of trisodium phosphate, or be aware of this to make the correct diagnosis. When triethanolamine. If the solutions are left in place too hydrofluoric acid penetrates under the free end of the long, they may irritate the posterior nail fold and de- nail plate, it causes tissue swelling and exquisite pain. stroy the cuticle, acting as a seal that prevents infec- Necrosis can eventuate in loss of the distal portion of tion [29]. Mechanical trauma accompanying this is the digit if the nature of the injury is not recognized discussed above. and treated promptly. For treatment, the nail plate is In the 1960s, nail hardeners were marketed that split or removed and calcium gluconate is injected di- were formaldehyde solutions and a series of reactions rectly into the nail bed or calcium gluconate is infused were reported that included onycholysis, paronychia, into the arterial supply of the effected digits [23].
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