How To Treat Dystrophic Nails

Author(s): 
Tracey C. Vlahovic, DPM

Pertinent Insights On Lichen Planus Of The Nail

Lichen planus is an idiopathic T cell-mediated inflammatory condition, which affects the skin, hair, nails and mucous membranes. This condition more commonly affects fingernails but in my practice, I have found this toenail disease to be more common than the literature describes.1

   Several nails are generally involved in presentations of lichen planus. The nails become thin, rough (trachyonychia), ridged longitudinally (onychorrhexis), fissured and can develop a dorsal wing formation of the proximal nail fold (or pterygium formation) over the nail plate. If the matrix damage from lichen planus goes unaddressed, these nail findings become permanent scarred reminders of the skin disease. Clinicians may address this by injecting steroids into the nail matrix.

Understanding The Presentation And Treatment Of Trachyonychia

Trachyonychia has also been referred to as “20 nail dystrophy” or rough nails. This is a benign condition that primarily affects children. One may see this in association with lichen planus, psoriasis, alopecia areata and atopic dermatitis. Clinicians may misdiagnose this condition as onychomycosis if they do not elucidate the underlying inflammatory condition causing trachyonychia.

   Treatment includes filing or buffing of the nails, oral biotin supplements, urea nail preparations and triamcinolone injections into the nail matrix. Trachyonychia may also spontaneously resolve with time.

What You Should Know About Trauma-Induced Nail Dystrophy

During a pedicure, the process of manipulating the cuticle may lead to Beau’s lines or depressions of the nail plate that are parallel to the proximal nail fold. Also, scraping of the hyponychium can lead to onycholysis, which provides a pocket for dermatophyte infection to take hold.

   Often due to shoegear, the fifth toenail becomes dystrophic and thickened.3 Patients and practitioners alike will confuse this with onychomycosis. If one sees this with concomitant onychomycosis and employs systemic treatment, he or she should discuss with the patient the possibility that the fifth toenail may not respond to oral antifungals. The underlying cause of the dystrophy can be biomechanical (an adductovarus fifth toe) or tight fitting shoes. A Lister’s corn or focal hyperkeratotic lesion that may appear to the patient as a “split nail” lateral to the nail plate may also be present.

   Onychauxis, onycholysis and discoloration secondary to the trauma of a severely contracted hammertoe may frustrate the patient who is pursuing antifungal therapy and questioning why a treatment regimen is not successful. In these cases, it is imperative to educate the patient about the biomechanical cause of the nail thickening and the treatment options. These range from purchasing a shoe with a deeper toe box to decrease pressure to surgical management of the digital deformity if warranted.

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