Treating Dystrophic Hallux Nails In A Six-Year-Old Boy
The most common form of onychomycosis in the lower extremity is distal lateral subungual onychomycosis caused by Trichophyton rubrum. Clinically, it may be difficult to distinguish onychomycosis from other existing nail pathologies. A KOH preparation, periodic acid Schiff (PAS) staining and fungal culture can aid in determining the presence of a dermatophyte-caused infection.
Onychogryphosis. Also known as ram’s horn nails, onychogryphosis results in an extremely elongated, dystrophic, claw-like curved nail that is often related to neglect of performing nail debridement for an extended period of time. Clinicians most often see this in the elderly population. It can also be related to shoe gear and/or biomechanical trauma, which causes one side of the nail to grow faster than the other. Accordingly, there is a characteristic curving of the nail plate.
Paronychia. One of the most common issues that drives patients into the office is paronychia of the great toenail or inflammation of the lateral and proximal nail folds, usually accompanying an incurvated and “ingrown,” or onychocryptotic nail plate. Purulence due to a Staph aureus infection generally occurs with this condition on the feet whereas Candida infection is more common in chronic thumb suckers. Ingrown toenails with accompanying granulation tissue at the lateral nail fold are generally painful and can be malodorous.
Treatment includes topical antibiotic and anti-inflammatory medications; oral antibiotic therapy; taping of the offending nail border to pull the inflamed skin away from the nail; education on proper nail trimming; incision and drainage of the abscess; and surgical removal of the onychocryptotic nail plate with or without chemical matrixectomy (phenol or sodium hydroxide).
Key Treatment Insights
When it comes to congenital malalignment of the great toenails, these nails may spontaneously regress in less than 50 percent of cases.6 Regarding other conservative measures, I also advocate nail debridement, partial nail avulsion if needed and finally taping. Arai and colleagues in Japan have described a simple taping method for onychogryphosis, which one can adapt to this type of dystrophy.7
From a surgical perspective, the best time to correct this deformity is before the age of 2 but I have corrected this condition in adults with success.8 The traditional treatment is a crescent-shaped resection that one carries back proximal to the nail bed and matrix.9 The surgeon would also excise a small triangular shaped area at the start of the proximal lateral incision in order to swing the whole nail unit so one can suture it in the appropriate orientation.
For this patient, I chose nail debridement followed by the Arai technique of taping, which one should repeat on a daily basis. I also prescribed a poly-ureaurethane, 16% nail solution (Nuvail, Innocutis) for the patient to apply nightly in order to create a smoother appearance and protect the nail plate. One should periodically monitor the patient for nail plate changes.
Dr. Vlahovic is an Associate Professor and J. Stanley and Pearl Landau Fellow at the Temple University School of Podiatric Medicine. She writes a monthly blog for Podiatry Today. Readers can access Dr. Vlahovic’s blog at www.podiatrytoday.com/blogs/556 .