Proper Preop Makes for Easier Toenail Surgery

April 15, 2007 • www.familypracticenews.com Skin Disorders 25 Proper Preop Makes for Easier Toenail Surgery

BY JEFF EVANS sia using a digital block or a distal approach to take ef- Senior Writer fect. Premedication with NSAIDs, codeine, or dextro- propoxyphene also may be appropriate, he said. WASHINGTON — Proper early management of in- To cut away the offending section of nail, an English grown toenails may help to decrease the risk of recur- anvil nail splitter is inserted under the nail plate and the rence whether or not surgery is necessary, Dr. C. Ralph cut is made all the way to the proximal nail fold. The hy- Daniel III said at the annual meeting of the American pertrophic, granulated tissue should be cut away as well. Academy of Dermatology. Many ingrown toenails are recurrent, so Dr. Daniel per- “An ingrown nail is primarily acting as a foreign-body forms a chemical matricectomy in nearly all patients after reaction. That rigid spicule penetrates soft surrounding tis- making sure that the surgical field is dry and bloodless. sue” and produces swelling, granulation tissue, and some- The proximal nail fold can be flared back to expose more times a secondary infection, said Dr. Daniel of the de- of the proximal matrix if necessary. Dr. Daniel inserts a Cal- partments of dermatology at the University of Mississippi, giswab coated with 88% phenol or 10% sodium hydroxide Jackson, and the University of Alabama, Birmingham. and applies the chemical for 30 seconds to the portion of For the early management of stage I ingrown toenails the nail matrix that needs to be destroyed. This procedure in which some granulation tissue but no infection is pre- is repeated three times, each time with a new Calgiswab. OTOLIA sent, Dr. Daniel said he has trained a nurse to push wisps /F The chemical then is rinsed out with saline or alcohol. of cotton gently under the ingrowing nail by using a 2- ORN An Ellman electrode can be used to electrodesiccate the H mm nail elevator or a 1- to 2-mm curette. This procedure matrix, followed by curettage. The CO laser also has

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can be repeated as often as is needed. ©J been used to perform a partial matricectomy after re- He also uses a technique for early-stage ingrown toe- Surgery should not be performed on a patient with an moval of the nail spicule and staining of the nail matrix nails in which dental floss is inserted under the ingrown ingrown toenail until the inflammation as been curbed. with methylene blue (Dermatol. Surg. 2005;31:302-5). nail corner without anesthesia and is kept there to sepa- After surgery, Dr. Daniel applies bacitracin/polymyx- rate the nail edge from adjacent soft tissue (J. Am. Acad. hold the gutter tube in place. The tubes are removed af- in ointment, followed by a Telfa pad, 2-by-2-inch or 4-by- Dermatol. 2004;50:939-40). ter the inflammation has subsided and the nail has grown 4-inch dressings, tube gauze, and then paper tape, mak- Dr. Daniel advises patients to combat the inflammation (Int. J. Dermatol. 2004;43:759-65). ing sure that the dressing is not too tight. present in early stages (without infection) by soaking the Dr. Daniel said surgery should not be performed on a The foot should be elevated as much as possible during toe for 10 minutes in 1-2 teaspoons of salt or Epsom salt patient with an ingrown toenail in a more advanced stage the first 24 hours and kept in an orthopedic shoe or old in a liter of cold water. After drying off the toe, patients until the level of inflammation has been reduced with salt tennis shoe with the toe cut out. After 48 hours, the toe apply a mid- to high-potency topical steroid to the nail fold. soaks in warm water (not cold, because of the possibility can be soaked in a warm salt bath for 20 minutes. Each These steps are repeated three times a day for 7-10 days. of infection) and topical application of steroids three soak should be followed with bacitracin/polymyxin oint- When the cotton, dental floss, and/or toe soak meth- times a day for about a week. He added that urea is not ment and a large adhesive bandage or bulky dressing. ods are used, he advises patients to apply 30%-40% urea often used in these cases because it doesn’t seem to work These steps are repeated three to four times a day for 1-2 twice daily to soften the nail plate and decrease rigidity as well as it does for early-stage ingrown toenails. In cas- weeks. Some physicians routinely add an oral antibiotic. and the “splinterlike” effect. es of suspected secondary infection, he usually prescribes Dr. Daniel formerly was on the board of directors for In one procedure, reported as being successful for 500 mg cephalexin (Keflex) four times per day; this pre- Doak Dermatologics, a subsidiary of Bradley Pharma- avoiding surgery, a plastic gutter tube is set under the in- scription may change if the bacterial culture and sensitiv- ceuticals Inc., which manufactures urea-based products grown part of the nail and acrylic is sculpted and allowed ity report indicates a different antibiotic may be better. for nail care. He holds stock options and has served as a to polymerize around the ingrown part of the nail and Before surgery, one should allow for time for anesthe- speaker, consultant, and investigator for the company. ■ Rosacea Lesion Count Drops Infant Atopic Dermatitis May With Use of Green Tea Cream Signal Elevated Asthma Risk

BY DENISE NAPOLI Tanweer Syed and colleagues wrote in a BY DOUG BRUNK al, children are enrolled in a double- Assistant Editor poster presented at the annual meeting of San Diego Bureau blind phase for 3 years, followed by a 33- the American Academy of Dermatology. month open-label phase for eligible par- WASHINGTON — Twice-daily applica- In this double-blind study, Dr. Syed— S AN D IEGO — Serum IgE levels are ticipants. The study presented at the tion of 2% polyphenone (–)-epigallocate- partial owner of Syed Skin Care Inc., San increased in children aged 3-18 months meeting was limited to baseline results. chin-3-gallate (ECGC [green tea extract]) Francisco, which sells a version of this with atopic dermatitis, suggesting they The mean age of patients at baseline in a hydrophilic cream significantly re- product—and coworkers randomized 500 are at risk of developing asthma and al- was 8 months, and more than half (62%) duced inflammatory lesion counts in pa- subjects (315 women) with papulopustu- lergies, baseline results from the Study of were male, reported Dr. Boguniewicz, a tients with papulopustular rosacea, Dr. lar rosacea into two groups. One group re- the Atopic March demonstrated. pediatric allergist with the National Jew- ceived 50 g of a hydrophilic cream con- The purpose of the Study of the Atopic ish Medical and Research Center in Den- Green Tea Extract taining 2% polyphenone ECGC; the other March (SAM) trial is to determine if treat- ver. The researchers conducted baseline received 50 g of a placebo cream. ment with pimecrolimus 1% cream in in- IgE tests on 926 of the children. The me- Successfully Treats Rosacea The patients (average age 30 years) app- fancy improves control of atopic der- dian total IgE level was 14 kU/L and was 74% plied the cream twice a day for 4 weeks, with matitis and reduces the incidence of higher for children with moderate atopic a maximum of 56 applications. They were asthma and allergies at 6 years of age, said dermatitis than for those with mild evaluated weekly using photographic and Dr. Mark Boguniewicz in an interview atopic dermatitis (a median of 18 kU/L optical techniques. Tolerability and adverse during a poster session at the annual vs. 11 kU/L, respectively). effects were graded according to duration (in meeting of the American Academy of The researchers also observed that days) and severity (mild, moderate, or se- Allergy, Asthma, and Immunology. children who had more severe atopic vere). Patients with connective tissue dis- In a multicenter study funded by No- dermatitis or who were older at baseline eases or acne, on immunosuppressive regi- vartis Pharmaceuticals Corp., which de- had higher total IgE levels, compared 20% mens, and with use of topical steroids within veloped and markets the pimecrolimus with children who had mild atopic der- EWS N the previous 12 weeks were excluded. 1% cream Elidel, Dr. Boguniewicz and his matitis or who were younger at baseline. After 4 weeks, 74% of patients in the ac- associates enrolled 1,091 infants aged 3-18 Baseline tests for antigen-specific IgE

EDICAL tive treatment group showed success, months who have a family history of showed that almost one-third (29%) were

Green tea extract Placebo M in hydrophilic cream meaning significant reduction in mean in- atopy and who had clinical evidence of sensitive to egg, whereas 25% were posi-

LOBAL flammatory lesion count, compared with atopic dermatitis for up to 3 months. tive to peanut, 22% were positive to milk,

Note: Based on a study of 500 subjects G after 4 weeks of treatment. 20% of those on placebo. Three-quarters of They conducted an allergy history and to- and 16% were positive to animal dander. Source: Dr. Syed the funding for this study was provided by tal and antigen-specific IgE assessments. Dr. Boguniewicz is a scientific advisor LSEVIER ■ ■ E Syed Skin Care Inc., the authors said. In the treatment component of the tri- to Novartis Pharmaceuticals Corp.