Onycholysis Dr Shyamalar Gunatheesan Skin Health Institute (Nail Clinic) 17/03/2021 Onycholysis • No conflict of interest Onycholysis • Detachment of the nail plate from the nail bed at the distal end and/or lateral attachments • Creates a subungual space that gathers keratin debris and dirt • Water accumulates, secondary bacterial and yeast infection • Not inflammatory unlike chronic paronychia • White or yellow discolouration due to air under nail, sequestered debris, shed squames and glycopyrotein exudate • Pseudomonas causes green/black discolouration Onycholysis • Idiopathic : • Psoriasis : Yellow , wavy margin between normal nail and separated area , glycoprotein deposition • Photo-onycholysis : sudden onset , due to drugs or chemical interaction with sun • ‘Sculptured onycholysis’, due to cleaning with sharp instrument • Hypothyroidism, hyperthyroidism, hyperhidrosis, impaired circulation Idiopathic onycholysis • Painless separation of the nail from the bed • Overzealous manicure, frequent wetting, cosmetic solvents • Minor traumatic element- more common in abnormally long nails • Affected nails tend to grow very quickly • Starts at the tip and extends to involve the distal third of the nail bed • Microbial colonization with Candida albicans and other bacteria. Idiopathic onycholysis • If the condition persists for several months, the nail bed becomes dark and irregularly thickened • Mostly seen in females • The longer it lasts, the less likely is the nail to become reattached due to keratinization of the exposed nail bed Psoriasis • 50% of psoriatics have nail involvement • Nail pits • Onycholysis • Subungual hyperkeratosis • Nail plate discolouration • Splinter haemorrhages • Acute and chronic paronychia Psoriasis- Onycholysis • Focal nail bed parakeratosis produces an oily spot or salmon patch • Extension of this area to the free edge produces onycholysis • Has a reddish brown margin • Or onycholysis may commence at the distal edge • Disruption of the onychocorneal band • Progressive Onycholysis due to psoriasis Psoriasis and onycholysis Onycholysis with damage due to acrylates Onycholysis with acute perniosis Mrs MM 72 year-old, 12m green nails Rx Itraconazole pulse X3, vinegar Onycholysis : tips • Lots of causes, patients usually have long nails, like to have manicures • Secondary pseudomonas causes green or black discolouration • Chronic candida infection may prolong course • Can try oral anticandidal agent, eg itraconazole 400mg/day for 1 week a month for 3 months • Fluconazole 200mg 2X/week Onycholysis: candida Rx Pre Rx Post itraconazole Onycholysis, candida Pre Fluconazole Post Fluconazole Onycholysis and pseudomonas Onycholysis post Rx Vinegar and itraconazole Pre and Post Fluconazole 75 year-old man, longstanding nail problems, culture negative, hyphae Post fluconazole 200mg 2/week 4 months Pre and post fluconazole Pre and Post Rx! Nails longer! Fluconazole • Demonstrates rapid uptake to the nail • Detected at the distal end of the nail plate within 1 day of treatment • With 150mg weekly for 12mths- detected in nail plate for at least 6mths after discontinuation • Inhibits cytochrome P-450 enzyme lanosterol 14@ demethylase with resultant inhibition in the conversion of lanosterol to ergosterol. Fluconazole- Safety profile • Well tolerated • Nausea, vomiting, diarrhoea • Rash • Headache • Rare side effects- paraesthesia hands and feet, confusion, seizures, dizziness • Rare severe liver disease • Leukopenia, agranulocytosis, thrombocytopenia, increased cholesterol Fluconazole • Ventricular dysfunction- congestive cardiac failure • Rare cases of prolongation of the QT interval • Caution with proarrhythmic conditions Fluconazole-Drug Interactions • Thiazides- reduces clearance of fluconazole • Calcium channel blockers-watch for edema and hypotension • Diabetic drugs- sulfonylureas- watch for hypoglycaemia • Statins- atorvastatin, lovastatin, simvastatin- risk of myopathy and rhambdomyolysis • Anticoagulants- warfarin- haemorrhage • NSAIDs- non selective and the COX-2 inhibitors • Hormonal contraceptives- effect unpredictable What’s new with nail psoriasis Rx? • Iontophoresis: small electrical charge to deliver medications through the skin • Dexamethasone: 100ml distilled water, 3ml dexamethasone sodium (8mg in 2ml) • Electrodes placed on the dorsum of the hands • 4mA of current applied through the solution • 20 mins • Weekly for 4-6 months IONTOPHORESIS Study of DI from 1996-2011 • 27 patients identified with adequate follow-up • All patients had at least 3 months of weekly DI • Some had other Rxs too eg creams • Photos taken before, during after • NAPSI scores done on photos Dexamethasone iontophoresis for the treatment of nail psoriasis- Quynh Van Le, Anne Howard Australas J Dermatol.2013 NAPSI scoring • The target nail is graded for features of nail matrix and nail bed psoriasis • Nail matrix psoriasis- Pitting, leukonychia, red spots in the lunula, nail plate crumbling • Nail bed psoriasis- Onycholysis, splinter haemorrhage, oil drop sign, nail bed hyperkeratosis • Max score per quadrant is 2 • Max score per nail is 8 Dexamethasone iontophoresis study • Treatment was ceased when no more improvement was being gained, or if patients developed side effects • NAPSI scoring was done by one investigator, no blinding. DI : Results • 18 female, 9 male, 30-83 years • Number of nails involved ranged from 1-10 (mean 8) • Number of treatments ranged from 9-102 (mean 42) • 22 patients showed some improvement ie 81% DI : results • 22 patients showed an improvement clinically and according to NAPSI scores ie 81% • 2 patients had no improvement according to NAPSI scores but improved said their nails felt stronger! • Range of NAPSI improvement was 1-25 (mean 8) DI : results • 3 patients had DI alone • Others had topical calcipotriol and steroids • One had oral anti-candidal therapy • 2 patients had relapses which responded to re- treatments • 1 patient had 3 relapses over 12 years and was successfully re-treated each time DI results • 5 patients failed to improve after 12-40 treatments • 2 of those patients were still happy with treatment! • One patient reported painful fissuring of the fingertips: this resolved with time Dexamethasone iontophoresis • Relatively easy to set up. • Relatively cheap • Very few side effects • Happy patients • Works best for distal nail disease ie onycholysis • Not set up for toenails! Pre and post iontophoresis Pre and post iontophoresis Pre and post iontophoresis Pre and post iontophoresis Pre and post iontophoresis Pre and post iontophoresis ?Iontophoresis for psoriasis, fluconazole for others, Mrs CG Pre and post fluconazole Toenails, trauma +/- fungal, psoriasis Summary : Tips for Onycholysis • Keep nails short, out of soaps and detergents • Do not use sharp objects under nails • Think of anti-yeast oral Rx , especially if there are hyphae on microscopy • Iontophoresis for nail psoriasis CONTACT Dr Shyamalar Gunatheesan Skin Health Institute (Nail Clinic) Speaker.