Congenital Malalignment of the Great Toenail (CMGT) Is Based on a Lateral Deviation of the Nail Plate

Home , Koilonychia, Leukonychia, Paronychia, Subungual exostosis

Review of Common Toenail Conditions and Current Treatment Options Dock Dockery, DPM

[email protected] Review of Common Toenail Conditions and Current Treatment Options

Dock Dockery, DPM

• These appear as indentations or grooves that run across the nails transversely. • In infants, these lines are commonly seen soon after birth. • In older children, they can be seen after a high fever, HFM Disease, trauma, or uncommonly, can be a sign of zinc deficiency or hypocalcemia.

• Gerard E et al. Risk factors, clinical variants and therapeutic outcome of retronychia: a retrospective study of 18 patients. Eur J Dermatol. 2016 Aug 1;26(4):377-381, 2016. • Akpolat ND and Karaca N. Nail changes secondary to hand-foot-mouth disease. Turk J Pediatr. 58(3):287-290, 2016.

PROXIMAL NAIL SHEDDING: ONYCHOMADESIS & BEAU’S LINES A. Damage occurs to the nail matrix: trauma, fever, illness, malnutrition, etc. B. Arrest in nail growth follows and then normal growth resumes. R L

R L

(B, D) Great toenail dystrophy of left great toenail presenting growth retardation compared to (A, C) normal right great toenail during 4 months. Arrow head is a CO2 laser marking. Onychomadesis is a periodic idiopathic shedding of the nails beginning at the proximal end, caused by the temporary arrest of the function of the nail matrix.

Onychomadesis with proximal nail fold paronychia Onychomadesis with proximal nail fold paronychia

de Berker, D, et al. Retronychia: Proximal ingrowing of the nail plate. J Am Acad Daermatol, 58:978-983, 2008. 16-year-old male with left partial hallux nail

14-year-old male with right hallux nail involvement 18-year-old male with left Great toenail dystrophy presenting with shrimp Total hallux nail nail or multiple onychomadesis events 11-years old 4-weeks old

6-years old

Congenital Malalignment of Great Toenail (CMGT) • Congenital malalignment of the great toenail (CMGT) is based on a lateral deviation of the nail plate. This longitudinal axis shift is due to a deviation of the nail matrix, possibly caused by increased traction of the hypertrophic extensor tendon of the hallux. • Congenital malalignment of the big toe nail is typically present at birth. Ingrown toenails, paronychia and onchogryphosis are among the most common complications. • Depending on the degree of deviation, conservative or surgical treatment may be recommended.

• Dockery G. Nail and periungual reconstruction, In, Lower Extremity Soft Tissue & Cutaneous Plastic Surgery, 2nd Edition, Ch 24, 2012. • Lipner SR and Scher RK. Congenital Malalignment of the Great Toenails With Acute Paronychia. Pediatr Dermatol.33(5):e288-289, 2016. • Richert B, et al. Cosmetic surgery for congenital nail deformities. J Cosmet Dermatol. 7(4):304-308, 2008. 12-month old male 6-month old male

His brother and sister had also experienced ingrown toenails since childhood. Conservative care: with daily foot bath of diluted povidone-iodine, gentle massage of nail folds and topical mupirocin. Cayirh M, et al. Congential malalignment of the great toenail, J Turk Acad Dermatol. 10:(1):161011, 2016. SURGICAL TREATMENT

From: Dockery G. Nail and periungual reconstruction, In, Dockery G and Crawford M: Lower Extremity Soft Tissue & Cutaneous Plastic Surgery, 2nd Edition, Ch 24, pp 289-305, 2012. 6-year-old

4-year-old 13-year-old

23-year-old • Koilonychia, a concave nail dystrophy, has multiple etiologies and may be hereditary, acquired or idiopathic. • These nails have a soft texture and appear scooped out, due to the thin, soft nature of a young child’s nails. They often occur on thumbs and hallux. • In infants, koilonychia of the toenails is commonly transient and idiopathic, although familial and syndromic cases are reported. • Koilonychias has been linked to iron deficiency, but mostly in adults.

• Walker J, et al. Koilonychia: an update on pathophysiology, differential diagnosis and clinical relevance. J Eur Acad Dermatol Venereol. 30(11):1985-1991, 2016. • Chinazzo M, et al. Nail features in healthy term newborns: a single-centre observational study of 52 cases. J Eur Acad Dermatol Venereol. 31(2):371-375, 2017. KOILONYCHIA (Spoon Nails) TREATMENT: Childhood koilonychia is typical of the toenails, whereas iron deficiency koilonychia is seen in both fingernails and toenails. It is not necessary to assess iron in a child with koilonychias of the toenails. Tests for iron deficiency should be pursued only if koilonychias is widespread and when it is seen in both fingernails and toenails. Leukonychia

Inherited leukonychia occurs at birth and leukonychia totalis occurs in early childhood days. CLASSIFICATION of LEUKONYCHIA: • True Leukonychia • Apparent Leukonychia • Pseudo Leukonychia 1. True Leukonychia: the white coloration is the result of pathology in the nail matrix. A. Hereditary: Autosomal dominant disorder with or without other medical conditions, B. Acquired: the result of nail matrix disturbances due to systemic disease, injury or poisoning. 2. Apparent Leukonychia: the pathology is within the subungual soft tissue. 3. Pseudo leukonychia: comes from an outside origin for example fungal infection (SWO) and excessive nail dehydration from nail polish. Inherited leukonychia occurs at birth and Leukonychia totalis occurs in early childhood days. LEUKONYCHIA: MUST rule-out Superficial White Onychomycosis (SWO) when dealing with Leukonychia. SWO scraps off easily with a fine curette, whereas leukonychia does not scrap off.

Superficial White Onychomycosis Superficial White Onychomycosis Leukonychia (puncta)

Also known as "true" leukonychia, this is the most common form of leukonychia. Picking and biting of the nails and micro-trauma to the base (matrix) of the toenail are a prominent causes in young children and nail biters. Besides parakeratosis, air trapped between the cells cause this appearance. When trauma is the case the white spots disappear after around eight months. • Onycholysis is the separation of a toenail from its nail bed. The separation occurs gradually and is usually painless. • The most common cause of onycholysis in children is trauma. Even slight trauma can cause onycholysis when it happens repetitively — for example, daily wear of tight socks or shoes, toe walking and activities like kicking. • Onycholysis is also commonly seen in toenail infections, especially onychomycosis, drugs and skin conditions. The ends of the nails become frayed and split. Commonly seen in the first few years of life, onychoschizia is usually present on the thumbs and big toes and thought to be due to repeated trauma. Must rule out anemia and malnutrition when many nails are involved. Koilonychia, onychoschizia of toenails or absence of lunula are physiological features of nails in newborns. Sarifakioglu E, et al. Nail alterations in 250 infant patients: a clinical study. J Eur Acad Dermatol Venereol. 22(6):741-744, 2008. Hochman LG, et al. Brittle Nails: Response to Daily Biotin Supplementation. Cutis. 51(4):303-305, 1993. Iorizzo M, et al. Brittle Nails. J Cosmet Dermatol. 3(3):138-144, 2004. Scheinfeld N, et al. Vitamins and minerals: their role in nail health and disease. J Drugs Dermatol. 6(8):782-787, 2007. CANDIDAL NAIL INFECTION

8-year-old boy

Candidiasis Onychomycosis Difficult to Treat Unless Proper Diagnosis is Made. ATOPIC DERMATOSIS Chronic Atopy w/ Xerosis & Nail Dystrophy in 12-YO Boy with Asthma and Upper Respiratory Bronchitis

Frequently misdiagnosed as tinea pedis and onychomycosis 6-Year-Old 13-Year-Old

Generalized: Accentuated skin Chronic Focal: Frequently lines & creases –xerosis misdiagnosed as tinea infection Intermediate Stage of Atopy: 7-Year-old boy Hyperlinear palmar Lichenification, dystrophic and finger creases nails, xerosis, accentuated lines ATOPIC DERMATITIS •MAJOR Features (Must Have 3 or More): •MINOR Features (Must Have 3 or More):

• Cheilitis (dry cracked corners of the mouth) • Conjunctivitis (recurrent) • Eczema • Keratosis Pilaris • Facial Pallor/Facial Erythema • Orbital Darkening • • Food Allergies or Intolerances Palmar Hyperlinearity • Pityriasis Alba • Hand Dermatitis • Wool Intolerance • Ichthyosis • Xerosis • Itching when Sweating Candida Paronychia Relhan V, et al. Management of chronic paronychia Indian J Dermatol. 59(1):15-20,2014. En Bloc Resection of Proximal Nail Fold

Chronic Candida Paronychia Rigopoulos D, et al. Acute and chronic paronychia. Am Fam Physician. 1;77(3):339-346,2008. Grover C, et al. En bloc excision of proximal nail fold for chronic paronychia. Dermatol Surg. 32(3);393-399, 2006. Subungual exostoses and osteochondromas more common on hallux than other toes.

• Tuzuner T, et al. Subungual Osteochondroma. J Am Podiatr Med Assoc, 96(2):154-157, 2006. • Lee SK, et al. Two distinctive subungual pathologies: subungual exostosis and subungual osteochondroma. Foot Ankle Int. 28(5):595-601, 2007. Vazquez-Flores H, et al. Subungual osteochondroma: clinical and radiologic features and treatment. Derm Surg. 30:1031-1034, 2004 Tuzuner T, et al.: Subungual osteochondroma. JAPMA 96 (2): 154 – 157, 2006. Mavrogenis A, et al. Skeletal osteochondromas revisited. Orthopedics;31:1018–1028, 2008. Vazquez-Flores H, et al. Subungual osteochondroma: clinical and radiologic features and treatment. Derm Surg. 30:1031-1034, 2004 Tuzuner T, et al.: Subungual osteochondroma. JAPMA 96 (2): 154 – 157, 2006. Mavrogenis A, et al. Skeletal osteochondromas revisited. Orthopedics;31:1018–1028, 2008.

Lee SK, et al. Two distinctive subungual pathologies: subungual exostosis and subungual osteochondroma. Foot Ankle Int.28(5):595-601, 2007.

Courtesy of Stephen Mariash, DPM

Ingrown toenails are one of the most common reasons for presentation due to nail problems in infants and early childhood. A. Daily massage and application of 2 drops of breast milk. Antiviral, Antifungal & Antibacterial. (Besides Streptococcus sp, researchers have found that breast milk sugars were also effective against two other pathogens including Staphylococcus aureus and Pseudomonas aeruginosa). If not breast feeding, then topical mupiricin. B. Daily massage with antibiotic ointment (mupirocin) to Spiculectomy. C. Partial nail wedge resection with phenol. Wedge resection plus phenol had a 4% recurrence rate, whereas the wedge resection only had a 2% recurrence. D. Partial Matrixectomy (Winograd-type) Preferred.

A. Mete E, et al. In vitro antifungal effect of human milk. Allergy Asthma Proc. 27(5):412-414., 2006. Bialik M. 9 surprising uses for breast milk, Tips on Life & Love, Sept 2013. B. Gioseffi ML, et al. Onychocryptosis in pediatrics: conservative treatment and spiculectomy. Arch Argent Pediatr. 108(3):244-246, 2010. C. Islam S, et al. The effect of phenol on ingrown toenail excision in children. J Pediatr Surg. 40(1):290-292, 2005. Mitchell S, et al. Surgical treatment of ingrown toenails in children, Ann R Coll Surg Engl, 93(2):99-102, 2011. D. Huang JZ, et al. Comparison of wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion in the treatment of ingrown toenails. J Foot Ankle Surg. 54(3):395-398, 2015. Use soft pencil eraser to push ingrown tissue

Tape, Steri-strip or bandaid strapping

Lazar L, et al. A conservation treatment for ingrown toenails in children. Pediatr Surg Int. 15:121–122, 1999.

1. Apply cream or lotion to toenails daily after bathing. 2. Trim toenails half as often as fingernails. 3. Use special nail scissors to trim nails but don’t bite the baby’s toenails. 4. Massage the skin away from the toenails with each diaper change. 5. Make sure socks and booties are not too tight. 6. See your podiatrist if any concerns or conditions present themselves.