Nail cosmetics are big business in the US. A specialist highlights some benefits of nail cosmetics and offers tips to protect your patients from potential dangers.

By Phoebe Rich, MD

38 Practical Dermatology October 2007 omen and men today value healthy, well- nails, it also makes them brittle, which is not desirable. Therefore, groomed nails. The appearance of the nails patients should avoid formaldehyde-containing products. may reflect overall health and good hygiene. Benzophenone is another allergen commonly found in nail For women, adornment of the nails may cosmetics. Nickel beads used in nail lacquers have largely been reflect a desire to accessorize or cosmetically replaced with polyester beads that are non-allergenic, howev- enhance the appearance the nails, whimsy, and/or artistic expres- er, the metal is still sometimes used. sion. Salon-applied nail enhancements can even help to camou- The clinical presentation of a reaction can help determine flage surface irregularities, such as pitting, or dystrophic nails the source of the allergen, based on the chemistry of the mate- resulting from dermatologic diseases like psoriasis. The range of rial used. Allergic contact dermatitis to acrylics usually pres- optionsW for nail adornment is wide, ranging from the simple ents in a periungual distribution with a hyperkeratotic or even application of polishes and lacquers to the use of acrylic nail vesicular-type reaction. Patients complain of pain, itching, and extensions to application of screen prints, jewelry, and more. burning, usually immediately after the nail procedure. Because There’s no doubt the cosmetic nail industry is large and acrylics polymerize very quickly, there is little opportunity for growing. In 2005, Americans spent $6.84 billion on salon transfer of the chemical, and the reaction is limited to the area services alone. This figure does not include spending on nail adjacent to the application site. care products and cosmetics from other sources, such as phar- By contrast, nail lacquer or polish hardens via evaporation macies and other retailers. Across the US, there are nearly rather than polymerization. Although a degree of hardening 400,000 licensed nail technicians at 54,000 salons. By con- happens very rapidly, full hardening occurs slowly over time. trast, dermatologists number around 12,000. The offending chemicals can be spread elsewhere on the body, Although there has been some widespread attention paid to including the neck and face. Eyelid involvement is very com- the issue of salon hygiene, the reality is that nail salons and nail mon, often in a focal distribution, though it may be diffuse. enhancements are not necessarily inherently dangerous. Millions Polyester resins have replaced tosyl formaldehyde resin of women use nail cosmetics with no complications. resin in over-the-counter and most salon products, but it may Nonetheless, by nature of the sheer volume of patients who fre- be found in some products. Patch testing easily and effective- quent nail salons, dermatologists are likely to encounter patients ly identifies allergy to tosyl formaldehyde, and a simple use who have experienced a negative outcome associated with a nail test can be performed. salon service. The majority of these problems will be linked Much development in the nail cosmetics industry comes from either to the materials used or to the mechanical procedures per- advancements in the plastics industry, and new acrylates contin- formed at salons. As dermatologists, we must be prepared to ue to emerge. To efficiently screen for acrylate allergies, test with effectively identify and treat potential nail problems and educate ethyl methacrylate, which cross-reacts most other acrylates, obvi- patients so that they can safely pursue nail salon services. ating the need to individually patch test for each form. Methyl methacrylate is highly allergenic and has been banned by most states but may be used in products in some AllergicReactions reactions. to Allergic Materials reactions associated with nail cosmet- discount salons because it is rather inexpensive. It is more ics are nothing new. In fact, the industry continues its efforts to durable than ethyl methacrylate, which replaced it and is gen- minimize the use of some common allergens and irritants. erally considered safer. Acrylates, of which there are multiple types, can be allergenic. Irritant reactions. Water is a significant irritant, and soak- Formaldehyde resin is one of the most common allergens associ- ing of the nails during a manicure can be problematic. ated with nail cosmetics. Although it is no longer used in over- Reaction to nail polish remover is probably the most com- the-counter nail products, it can be found in some salon products. monly seen irritant contact reaction. Acetate has largely Formaldehyde can still be found in some nail cosmetics. replaced acetone as the primary ingredient in nail polish According to FDA regulations, formaldehyde may be present in removers, but it is only slightly less dehydrating. nail cosmetics and hardeners in concentrations below three per- Contact irritants can produce various clinical presenta- cent, and such products should not be intended to touch the skin. tions, the most common of which are paronychia, onycholy- However, these federal guidelines apply to products traded across sis, and brittle nails. state lines, so it is possible for an in-state manufacturer to produce Paronychia results from a cycle initiated by loss of the cuti- and locally distribute formulations that contain higher concentra- cle as a result of the irritant reaction. Absence of the cuticle tions of formaldehyde. This is the case in my home state of permits moisture, yeast, and bacteria to enter the nail fold, Oregon, where I have seen patients react to a local product that leading to inflammation and paronychia. Onycholysis may contains formaldehyde. Although formaldehyde hardens the result from irritation caused by water or nail polish remover.

October 2007 Practical Dermatology 39 Nail Cosmetics

Onychoschizia—peeling and brittleness at the nail tip—is most common in individuals who frequently remove nail pol- ish. Some women change polish several times weekly to match outfits or simply on a whim. However, we recommend that patients remove polish only one time weekly. Note that nail yel- lowness among women who fre- quently paint their nails likely results from staining or discol- oration produced by nail enam- el dyes. Keratin granulations may also occur in patients who remove nail polish frequently as well as in individuals who leave pedicures in place for prolonged periods of time (three months is common). Allergic contact dermatitis (top, left). Atypical mycobacterium as seen in patients after pedicures given in con- These granulations are not fungal taminated water (top, right). Brittle nails/onychoschizia (bottom, left). Keratin granulomas (bottom, right) . and are thought to be produced by the base coat, though this is not proven. avulsion, you will feel some give when you hit the matrix. When pressure is applied to long artificial nails, which are harder than natural nails, the nail will not bend or fracture. Instead, the nail MNailany Traumacases of nail trauma result from procedures performed will act as a lever and pull away from that loosely adhered nail in the nail salon. Mechanical problems may result in onychol- matrix. A natural nail, by contrast, is much more flexible, and ysis and paronychia. The most common cause of trauma is use would quickly bend or fracture under pressure. of sharp instruments, such as clippers, metal cuticle pushers, Mechanical problems can lead to infection, bacterial, fungal and electric drills. Electric dremel drills are used to file thick (primarily dermatophyte and yeast), or viral. Infections can be acrylic nails and to shape or file natural and artificial nails. If spread from client-to-client in the salon when tools are not sani- the drill slips, it can cause damage to the nail and/or trauma tized. A case of fatal MRSA following a pedicure has been docu- and cuts to the skin that may lead to infection. Furthermore, mented. This specific case involved a paraplegic woman. The gen- the drill tips may not be sanitized or changed regularly and eral recommendation is that paraplegics and diabetics avoid pedi- may be used from client-to-client, introducing the possible cures, since they may not detect cuts and nicks that may lead to spread of infection. Home drill kits are also available. While serious infection. Such extreme cases are thankfully rare, but these personal use devices limit the threat of infection spread, infections can occur with some frequency. their use can cause damage in and around the nail unit. When patients present with paronychia, attempt to culture Clipping of the cuticles or manipulation with sharp metal pus from the area in order to make a specific bacterial diagno- cuticle pushers can damage the cuticle, decreasing defense sis and institute appropriate antibiotic therapy. Dark nails against infection. A poorly sanitized clipper may even intro- associated with onycholysis are usually associated with duce infection. We advise patients to never clip their cuticles. pseudomonas, though there may be other causes. Long natural or artificial nails can act as a lever that lifts the There is potential viral spread by incompletely sterilized pedi- nail plate whenever pressure is applied to the nail tip. cure implements. Paring of a wart that is misdiagnosed by the Constant use of the hands—typing, opening cabinets, etc.— patient or salon technician as a callous, for example, can lead to produces chronic minor trauma that can lead to onycholysis viral spread for the individual and among clients. Herpetic whit- and splinter hemorrhages among other issues. low may be associated with nail services. The nail plate naturally is attached tightly to the nail bed but Pedicure procedures may present a unique opportunity for loosely over the matrix. For this reason, when performing a nail infection. In one case, roughly 100 clients at one salon expe-

40 Practical Dermatology October 2007 rienced boils and furuncles of the legs as a result of a traced back to a scrub nurse. At a neonatal intensive care unit microbacterium. The women had shaved their legs prior to in Oklahoma, 46 cases of psuedomonas infections (15 of the using a footbath—a common element of pedicures. Evidently, babies died) were linked to two nurses. One of the nurses had the water was contaminated, and it infected the women. artificial nails, and the other had long natural nails. Footbaths circulate water through a filter intended to col- lect debris. If the filter is not properly cleaned, debris caught in it can serve as a reservoir for infectious agents, even if the ANew growing Developments trend in nail cosmetics is the incorporation water is drained and replaced with fresh water for each client. of sunscreens to protect the manicure from discoloration. Guidelines state that footbaths should be run with a bleach Patients may believe the sunscreen is intended to protect the solution for at least 15 minutes between clients, but this is not nail and may question whether they should be applying often the case at busy salons. sunscreen to the nails. Advise patients that this is not necessary. The market for antimicrobial products distributed by nail salons also appears to be growing. Several topical anti-fungal ThereAnother is some Risk controversy regarding nail cosmetics in the products are sold for treatment or prevention of onychomy- healthcare setting. Some medical practices ban artificial nails cosis, and some products target bacteria. Data on these prod- for staff. Many hospitals and operating room nurse associa- ucts are limited, but patients should recognize that ony- tions have either banned artificial or long natural nails or at chomycosis or acute paronychia require medical attention least recommend against them. and probably prescription medication. The threat posed by artificial nails in the healthcare setting Tea tree oil is one ingredient that is particularly popular as an is unproven, but there is cause for concern. Three patients antimicrobial agent. While it does demonstrate some beneficial developed Candida osteomyelitus following surgery that antimicrobial effects, it is also a potential allergen. Question Nail Cosmetics

Continuing education is not standard, either. There are typi- cally too few inspectors to adequately police all salons. (See text for full discussion.)Nail Tips We as dermatologists can take an active role in educating • Allergic contact dermatitis to acrylics usually presents in a local salon technicians about the importance of safe and hygien- periungual distribution with a hyperkeratotic or even vesicular- ic practices. Basic education about nail health and possible signs type reaction. and symptoms of nail disease could also prove beneficial. In • Nail lacquer or polish hardens via evaporation; full harden- some cases, the technician may be the only person beside the ing occurs slowly over time. Offending chemicals can be patient who ever sees the naked nail. If technicians could alert a spread elsewhere on the body, including the neck and face. client to potential problems, including possible cancers, the indi- Eyelid involvement is common. vidual could seek full evaluation by a dermatologist. • Federal guidelines limit formaldehyde concentrations in nail We must also emphasize education of patients, particularly products to 3%, but an in-state manufacturer may produce those who visit nail salons: and locally distribute formulations containing high concentra- • Above all, encourage patients to use only reputable tions. salons. As a general rule, if the salon seems dirty or sub-par, it • To efficiently screen for acrylate allergies, test with ethyl probably is. methacrylate, which cross-reacts most other acrylates. • Instruct patients to use only licensed technicians and salons. • Reaction to nail polish remover is a common irritant contact They should physically view licenses, which should be on display. reaction. Patients should remove polish one time per week. • Patients should question the salon about its sanitation prac- tices. Some salons employ hospital level sterilization procedures • Advise patients to never clip their cuticles. Damage to the and have on-site autoclaves, and patients can trust such measures. cuticle decreases defense against infection. • If hospital-level sterilization is not enforced or clients are • When patients present with paronychia, attempt to culture skeptical, advise patients to purchase and bring to each salon pus from the area in order to make a specific bacterial diag- visit their own tools and implements. These are available at a nosis and institute appropriate antibiotic therapy. pharmacy or beauty supply store. Some salons even sell or dis- • Dark nails associated with onycholysis are usually associat- tribute tool packs to patients. ed with pseudomonas, though there may be other causes. • All patients should also purchase their own manicure or • Paraplegics and diabetics should avoid pedicures; they may pedicure packs containing items like pumice stones, files, and not detect cuts and nicks that may lead to serious infection. foam toe separators, etc. that cannot withstand sterilization procedures. Though not proven, I suspect that foam toe sepa- patients about product use, including tea tree oil, when the rators could be a significant source of infection transfer. source of allergic contact reaction is not immediately evident. • Patients should never allow their cuticles to be cut. It is worth noting that the popularity of pedicures is grow- • If pain, itching, or stinging develop, go to a dermatolo- ing, and toenail care is becoming more complex. Increasing gist for evaluation. These symptoms may even develop during amounts of patients apply acrylic nails to the toes now. salon services. Immediately stop and seek dermatologic care. • To minimize infection risk, particularly for those in healthcare, keep artificial or natural nails short. SalonsSafety overall Education seek to provide safe and hygienic services to • Patients should not shave their legs within 24 hours of a patients in order to attract and retain clients and avoid poor pedicure to reduce risk of infection from pedicure spas. outcomes and their repercussions. The industry is making efforts at self-policing. The Nail Manufacturers Council (now part of the Professional Beauty Association) published salon NailThe adornment Dermatologist’s is popular today, Role and a majority of our patients regulations to help ensure safety and is involved in ongoing are probably visiting salons for services at least on an occasional education programs, including a magazine for technicians. basis. As dermatologists, our primary function is to help patients Some salons are still potentially problematic. These tend to be evaluate sources for nail care and identify safe alternatives if and discount salons that offer cut-rate services. Encourage patients when reactions occur. We may even recommend nail cosmetics to avoid any such salons. to patients to camouflage dystrophic nails, nail pitting, and other Despite industry-wide efforts, state board regulation and surface irregularities resulting from conditions like psoriasis. licensing issues are inconsistent. There are no national stan- Finally, we can help protect patients by being a resource for local dards for accreditation of technicians. Some states require just technicians, sharing advice about safe, hygienic techniques and four weeks of training, while others require 18 months. helping to increase the level of salon safety.

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