A Guide To Detecting Nail Pathology

By Bradley W. Bakotic, DPM, DO

   As all those who specialize in the treatment of lower extremity ailments will acknowledge, there is nothing uncommon about nail unit pathology. Though pristine appearing nail units are commonplace in children, advancing age may bring a combination of acute and chronic trauma, neoplastic processes, non-infectious dermatological diseases, and bona-fide mycotic and non-mycotic infections that take their toll. These stressors manifest as alterations in nail color, shape and/or texture.    Too often in mainstream medicine, there is a tendency to attribute such changes within the nail unit solely to onychomycosis, leading clinicians to rely on oral or topical antifungal medications as “silver bullets” in their management. Such ill-fated reliance may lead to presumed drug inefficacy as even a perfect antifungal can only eradicate the organism if it is there. Often fungal infections are indeed present but represent a secondary phenomenon affecting a nail unit that was originally altered by a different pathologic process. In these cases, the best that one can hope for is a mycotic cure but a clinical failure.    To fine tune our management of patients with nail unit dystrophy, we might benefit by viewing the problem as a constellation of several factors as opposed to equating nail unit dystrophy with onychomycosis. By assessing all the possible contributors to the nail unit abnormality, we will recognize the various processes that must be addressed in addition to, or in lieu of, antifungal therapy.

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