1/15/2020 Learning Objectives By the end of this activity, learner will be able to: Brian Z. Rayala, MD • Assess normal nail anatomy and identify common disorders. How to Treat • Associate Professor of Family Medicine, • Describe the appearance and clinical significance of the most that Ugly, UNC School of Medicine common nail disorders. • Director of Procedural Training, UNC Painful Toe Family Medicine Residency • Evaluate treatment options and indications for nail bed surgery and repair. • Counsel patients on proper nail care to avoid infections or the development of nail abnormalities. 1 2 1 Nail Anatomy Nail Disorders • 45yo female, diabetic, S/P 4 th & 5 th toe amputation • 7-yr hx of nail discoloration, hypertrophy, onycholysis, and subungual debris • Otherwise asymptomatic 1. Am Fam Physician. 2012;85(8):779-787. 3 4 Nail Disorders Onychomycosis: Classification Diagnosis: Etiology/Epidemiology: 3 • Onychomycosis , or • Accounts for 50% nail problems • Tinea unguium , or • Prevalence: 10% of U.S. population, 20% adults >60yo, 50% adults >70yo • Nail dermatophytosis • Dermatophytes ( Trichophyton ), nondermatophytes (Candida ), saprophytes Anatomic location: (molds) • Nail plate and nail bed Clinical features: Risk factors: 2 • Discoloration, hypertrophy, onycholysis, • Psoriasis, tinea pedis, advancing age, subungual debris household contact, regular swimming, immune-suppression (diabetes, HIV) • Distal lateral subungual (big toe) 2. Essential Evidence, updated 7/20/17. • Total dystrophic (all toenails) 3. Am Fam Physician. 2013 Dec 1;88(11):762-70. • Superficial (3 rd / 4 th toes) 5 6 1 1/15/2020 Onychomycosis: Onychomycosis: Evaluation and Management Evaluation and Management 3 Evaluation: Medication 3 Mycologic Clinical Cost Drug Monitoring Medication 3,4 Mycologic cure Clinical Cost cure cure Interactions cure Perform KOH microscopy of nail 7 • Terbinafine 76% 66% $4/ Antiarrhythmic, LFTs, Cr at baseline; Ciclopirox 8% soln 29-36% 6-9% $75 for NNT (Terbinafine for Onychomycosis) clippings & subungual debris 250mg QD x 6- mo BB, SSRI, TCA, CBC if >6wk tx in (Penlac nail lacquer) qhs (77% w/ 6.6mL • 8-10 nail shards 12wks warfarin immunosuppressed x 48wks debridement) bottle Efinaconazole 10% soln 53-55% 40-45% $577 for • 1 in 3 cured compared w/ placebo • Confirm hyphae, pseudohyphae, or spores Itraconazole 63% 70% $162/ Benzo, CCB, PPI, LFTs at baseline, (Jublia) QD x 48wks 4mL (pulse dosing) mo statins, warfarin then periodically if 1 in 10 cured compared w/ azoles • To identify organism, consider: bottle • 200mg BID x >1mo tx or w/ Tavaborole 5% soln 31-36% 26-28% $1,509 for • Fungal culture (takes 4-6 wks) 1wk per month hepatic impairment (Kerydin) QD x 48wks 10mL • 1 in 3 cured compared w/ griseofulvin • Histologic exam w/ PAS stain (24 hrs) (2-3 mos) bottle Itraconazole 59% 70% $324/ Test Sensitivity 5 (continuous) mo Cochrane Review (2007) KOH 48% Culture 53% 200mg QD x 6- • Ciclopirox: 61-64% failure rate PAS 82% 12wks Cochrane Review (2017) 6 KOH + culture 74% Fluconazole 48% 41% $12/ Benzo, CCB, Cr at baseline; LFTs KOH + PAS 89% 100-300mg qwk mo statin • Cure rates: terbinafine > azoles = griseofulvin 3. Am Fam Physician. 2013 Dec 1;88(11):762-70. x 3-6mos or 6- 4. J Pharm Pract. 2017 Apr;30(2):245-255. Culture + PAS 96% • Adverse events: terbinafine = azoles < 5. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001434. 12 mos 6. Cochrane Database Syst Rev. 2017 Jul 14;7:CD010031. griseofulvin 7. Am Fam Physician. 2018 Aug 1;98(3):online. 3. Am Fam Physician. 2013 Dec 1;88(11):762-70. 7 8 Onychomycosis: Evaluation and Management Nail Disorders Top 20 POEMS of 2017: 8 Practice Pearls: • Cost-effectiveness analysis of 3 approaches • Treat only if there’s a compelling reason! • Empiric tx w/ terbinafine w/o testing • Educate patient about mostly cosmetic • 25yo healthy male • KOH (w/ PAS prn) before tx problem. • PAS before tx • Address modifiable risk factors (e.g., DM). • 4-wk hx of pain, redness, drainage on lateral aspect of R • Outcomes: direct cost of testing, cost to avoid harm • Manage nail thickness using debulking great toe lateral nail fold w/ terbinafine methods. • Results: empiric tx w/ terbinafine saves $47 • formation of friable granulation tissue compared w/ KOH & $135 compared w/ PAS. • Mentholated ointment helps keep nail from • Testing to prevent single case of liver toxicity crumbling, and may have anecdotal costs $18-43M for KOH, and $38-90M for PAS. evidence of efficacy. • Efinaconazole: KOH saves $272 & PAS saves • Oral terbinafine is most cost-effective tx. $406 per pt per nail • Remember, recurrence rate 10-50% • Conclusion: Tx empirically w/ terbinafine; but regardless of tx method! 3 consider PAS testing for efinaconazole 3. Am Fam Physician. 2013 Dec 1;88(11):762-70. 8. JAMA Dermatol. 2016 Mar;152(3):276-81. 9 10 Nail Disorders Onychocryptosis: Classification Diagnosis: Etiology/Epidemiology: 9,10 • Onychocryptosis , or • 20% of pts presenting w/ foot problems to • Unguis incarnatus , or PCP Nail punctures lateral nail fold resulting in • Ingrown toenail • cascade of FB, inflammatory, infectious & reparative processes Anatomic location: • Lateral nail fold, often of the big toe Clinical features: • Erythema, pain, edema of lateral nail fold; Risk factors: 9,10 exudate • improper nail trimming, constricting • Granuloma formation footwear, acute or repetitive trauma, • Nail fold hypertrophy genetics, hyperhidrosis, poor foot Stage 2: Moderate hygiene, conditions that cause edema Stage 3: Severe 9. Am Fam Physician. 2009;79(4):303-308, 311-312 Stage 1: Mild 10. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD001541. 11 12 2 1/15/2020 Onychocryptosis: Onychocryptosis: Non-surgical Interventions 10 Surgical Interventions 10 10 Cochrane Review (2012) 10 Cochrane Review (2012) • 5 of 24 included studies • 19 of 24 included studies • Surgical better than non-surgical • Non-surgical tx were inferior interventions to prevent recurrence to surgical tx in terms of • Adding phenol decreases recurrence recurrence & regrowth; infection rates unchanged . • Postop abx and topical therapies do not decrease infection & pain, nor hasten healing. 10. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD001541. 10. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD001541. 13 14 Video: Partial Nail Avulsion w/ Onychocryptosis: Chemical Ablation Partial nail avulsion w/ phenol matrixectomy Practice Pearls: • If possible, treat mild cases or first episode, esp. among poorly controlled diabetics, non-surgically. • Prior to surgery, assess vascular status of foot/toe, esp. among diabetics and those with PAD. • Consider surgery for recurrent mild cases, and for moderate to severe cases. • Perform phenolization, but do not routinely administer postop abx. • Provide proper nail care advice (see later discussion). Phenol matrixectomy 15 16 Nail Disorders Nail Disorders Diagnosis: Etiology/Epidemiology: 11,12 • Paronychia • Incidence & prevalence not available • Acute (<6 wks) vs. chronic (≥6 wks) • Acute paronychia – most common hand infection in U.S. (3:1=women:men) • 30yo healthy male • Disruption of protective nail barrier Anatomic location: • 2-day hx of pain, swelling, redness, and fluctuance along • Acute – polymicrobial (staph, strep, the proximal and lateral nail folds, R thumb • Proximal or lateral nail folds, often Pseudomonas , anaerobes) involving the fingernails Chronic – often colonized by fungus ( Candida , • 4 days earlier, pulled a “hangnail” along lateral nail fold • dermatophytes, etc.), but not true pathogen Risk factors: 11,12 Clinical features: • Acute : trauma • Pain, erythema, edema of perionychium • Chronic : trauma, excessive moisture, • Induration or fluctuance (abscess) contact irritants, immune-suppression • Chronic : nail plate changes; loss of cuticle (diabetes, HIV), medications (EGFR 11. Essential Evidence, updated 7/29/17. antagonists, antiretrovirals) 12. Am Fam Physician. 2017;96(1):44-51. 17 18 3 1/15/2020 Paronychia: Classification Paronychia: Management 11,12 Acute Chronic 11,12 • Conservative mx (e.g., warm soaks +/- • Stop source of irritation ( SORT C ) Burow soln or 1% acetic acid) - SORT C • Topical steroids more effective than • Topical abx (e.g., mupirocin, systemic antifungals ( SORT B ) gentamicin, fluoroquinolone) +/- • Other options: topical anti- inflammatory agents, calcineurin topical steroids – SORT B inhibitors ( SORT B/C ) • Oral abx (e.g., clindamycin, • Consider eponychial marsupialization amoxicillin/clavulanate) for cellulitis & or en block resection +/- nail plate immunocompromised - SORT C removal for recalcitrant chronic • POCUS , I&D for abscess - SORT B paronychia ( SORT B ) Acute paronychia w/ abscess Chronic paronychia 11. Essential Evidence, updated 7/29/17. 12. Am Fam Physician. 2017;96(1):44-51. 19 20 Nail Disorders Nail Disorders Diagnosis: Etiology/Epidemiology: 13 • Subungual hematoma • common presentation for acute digit pain • 28yo healthy male and nail bed discoloration • 3-wk hx of black pigmentation of proximal nail Anatomic location: • trauma causes bleeding from vascular nail bed • asymptomatic • space between nail plate and bed • no personal or FH of melanoma Clinical features: 13 • hx of trauma 1 wk prior Risk factors: • Acute – tender, purplish-black • trauma discoloration of nail bed • Subacute – non-tender, crescent-shaped black discoloration that advances with nail growth 13. Am Fam Physician. 2012;85(8):779-787. 21 22 Subungual hematoma Subungual hematoma: Management Acute 13 Subacute • Puncture nail plate using • no treatment hot metal