How To Treat Dystrophic Nails

Tracey C. Vlahovic, DPM

   Proximal subungual onychomycosis. It is common to see this in immunocompromised patients as a leukonychia or white discoloration of the proximal nail plate. One generally does not see distal subungual debris in this manifestation. Trichophyton rubrum and non-dermatophyte molds are the common pathogens in this nail disease.

   Candidal onychomycosis. Onychomycosis caused by Candida most often occurs in patients who have chronic mucocutaneous candidiasis. The nail can present with onycholysis and paronychia.

   Superficial white onychomycosis. The white powdery material one sees with this type of onychomycosis is present on the dorsal aspect of the nail plate. Clinicians can scrape this off with a scalpel blade. One sees this condition in patients in tropical climates and it is typically caused by Trichophyton mentagrophytes or non-dermatophyte molds. Clinicians may mistakenly identify proximal subungual onychomycosis as superficial white onychomycosis in very young children due to their thin nail plates.

   Treatment for onychomycosis includes targeting the causative organism with either oral terbinafine (Lamisil, Novartis), oral itraconazole (Sporanox, Janssen Pharmaceuticals) in pulsed doses, oral fluconazole (Diflucan, Pfizer) in once-a-week dosages, oral griseofulvin (Grifulvin V, OrthoNeutrogena) or topical ciclopirox lacquer (Penlac, Sanofi-Aventis) among many other over-the-counter and compounded remedies.

   It is also standard to employ mechanical debridement to debulk the nail unit to allow better penetration of topical medications and increased comfort in shoes. Clinicians may also use topical urea preparations to soften and smooth the nail plate, and apply a laser such as the 1064 nm YAG to theoretically create an inhospitable environment for the dermatophyte.

What To Look For With Nail Psoriasis

Psoriasis can affect the skin, nails and joints. Classically, psoriatic nail disease consists of: onycholysis; salmon (oil) spots (discolored areas that represent nail bed psoriasis); an irregular pitting pattern; and onychauxis. The Koebner phenomenon, or the appearance of lesions at the site of injury, can also occur in the nails and may manifest in an asymmetrical presentation. If a patient presents with an onychomycosis-like nail involvement and has failed oral antifungals, one should consider a diagnosis of psoriatic nail disease.

   Also, if psoriatic plaques and nail dystrophy are present, they do not automatically lead to a diagnosis of psoriatic nail disease.1 This is why culture and biopsy with negative PAS stain are essential to achieve the correct diagnosis. In addition to the nail changes, periungual erythema may be present. Patients may also present with the arthritic component of psoriasis, which may manifest in dactylitis of the digits (sausage toes), enthesitis of the Achilles tendon and distal interphalangeal joint involvement.

   Management of nail psoriasis involves reducing the inflammatory response. The most common treatments include: injection of a corticosteroid (such as Kenalog, Bristol-Myers Squibb) into the nail matrix; the use of topical calcitriol (Rocaltrol, Roche USA), calcipotriene (Dovonex, Warner Chilcott) or tazarotene (Tazorac, Allergan); oral acitretin (Soriatane, Stiefel Laboratories); or the use of systemic infliximab (Humira, Abbott Laboratories).

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