With nail art and pedicures on the rise over the last few years, podiatrists must be vigilant on the potential risks for patients. In addition to these issues, this author discusses potential dilemmas that can emerge with the use of gel nails and acrylic nails.
Nail art and adornment are visual extensions of personal style and have exponentially expanded in the last few years. Each month, Google logs 2.5 million searches for “nail art.”1 Social media, especially Instagram and Pinterest, have launched the careers of amateur nail artists and allowed celebrities to push this trend forward as well. In 2012-13, salon customers spent a record-breaking $7.47 billion in nail services.1
With financial growth like that, it is important that we as practitioners recognize the types of cosmetic nail services available, treat the possible complications of these services and contribute physician-based products and services to the mix.
The ingredients for nail polish have changed minimally since its debut. Nail polish usually consists of “pigments suspended in a volatile solvent to which film formers have been added.”2
One of the primary film formers in nail polish is nitrocellulose, which creates a film that adheres to the nail plate and allows for oxygen permeability, ultimately creating an inactive and non-damaging coating on the nail plate. In addition to a compound that will create a shiny, tough surface, the polish must include a secondary film forming resin for flexibility or the polish will crack. The resin is toluene sulfonamide formaldehyde but this compound is highly allergenic and many polishes, especially those labeled hypoallergenic, have removed the compound. Other resins have replaced the resin but these can cause the polish to be more brittle and still can cause an allergenic response.
Besides nitrocellulose and toluene sulfonamide formaldehyde, nail polish also consists of plasticizers (to keep the product flowing in the bottle), solvents, colorants and specialty filters (to create various specialized effects on the nails).
Typically, home nail polish application consists of three layers: a base coat that is generally clear and helps the pigmented polish to adhere and prevent chipping of nail polish; nail polish to camouflage the underlying nail plate; and finally a top coat that is also clear, leaves a shiny finish and provides further protection against chipping.
For those who have difficulty applying nail polish, two products have emerged to assist with application. The Plié Wand™ (Julep) boasts an elongated, flexible handle that allows the non-dominant hand to polish with minimal difficulty.3 Salon Effects Real Nail Polish (Sally Hansen) strips allow those who would not be able to apply nail polish to press on stickers made from nail polish to their fingers and toes.4 People typically remove these products with regular nail polish remover.
Nail art has emerged as a way to express oneself and be fashionable. Every imaginable color is available as nail enamel (from neutrals to neon) and various finishes and instruments are available to create nail art. In recent years, everything from nail polish that reacts to the magnet in the cap to create patterns to adornment with sequins, small crystals and/or whimsical embellishments on top of the nail enamel is available in home kits and salons.
Nail polish itself is a relatively safe product for either gender or pregnant women to use.4 However, it is my experience to see two side effects from using nail enamel: discoloration of the nail plate from particular colors and allergic contact dermatitis. Staining of the nail plate is very common with the vivid red and purple polishes. This typically casts a yellowish hue on the nail plate that may last up to 14 days or longer following polish removal. Patients and physicians often mistake this yellow hue for onychomycosis. A simple scraping of the nail with a #15 blade can confirm that it is a surface stain.4
Regarding allergic contact dermatitis, most who present with nail fold erythema and edema as well as possible eyelid dermatitis (from scratching the eye with the polished fingernail) are allergic to the aforementioned toluene resin.5 One can confirm this through patch testing and encourage those patients to purchase 3-free or 5-free nail polishes that are free of toluene, formaldehyde and dibutyl phthalate (5-free polishes include formaldehyde resin and camphor) (See the table “A List Of 5-Free Nail Polishes To Recommend To Patients” above at right).6
Understanding The Dynamics Of Pedicures
While home pedicures can certainly create issues, salon-based services carry the risk to cause a more severe series of issues: infection, trauma and allergic reactions to name a few. In order to best assist our patients who have developed a complication following this service, it is important we understand the protocol of a pedicure.
First, technicians remove any previous nail polish with nail polish remover. Then they soften the nails and cuticles with a soak or a foot bath. The technician subsequently uses a metal device or orange stick to clean the hyponychium to loosen any debris. Technicians apply cuticle remover and “push back” or remove cuticles with various instrumentations. If nails are stained, a bleaching agent such as hydrogen peroxide may help and if there is any ridging on the nail plate, the technician may buff the nail. Nail technicians use a nail file to shape the nails and then apply the three-step system mentioned earlier (base coat, polish and top coat), possibly following with a drop or spray to assist the drying time process.7
The hyponychium and true cuticle (the colorless and sticky structure on the dorsal surface of the nail plate) are waterproof barriers that seal the nail unit from infection and the outside world.7 Disrupting those barriers can create a paronychia (defined simply as inflammation of the periungual region, not as an infected ingrown nail), onycholysis (separation of the nail plate and nail bed), and infection from bacteria, fungus or viruses.
Onycholysis, presenting often as a whitish discoloration at the distal edge of the nail plate following a salon nail service, creates a small pocket of dead space that bacteria, fungus or yeast can colonize. If Pseudomonas is the culprit, the nail will appear greenish. However, if a dermatophyte such as Trichophyton rubrum has taken hold of the area, then the yellowish-brown discoloration associated with onychomycosis may potentially be visible.
In addition to these pathogens taking advantage of spaces created by the sharp instruments in a pedicure, infection from the multi-use instruments (nail clippers, cuticle nippers, drills) is a widespread and dangerous side effect of having a pedicure.7 The Centers for Disease Control and Prevention (CDC) consider these instruments “critical items” or implements that enter sterile tissue or the vascular system. Critical items are associated with a high risk of infection if contaminated and one should autoclave them. Liquid immersion in chemicals is also an alternative to rid the instruments of spores from bacteria and fungus. This includes immersing the critical items in hydrogen peroxide for six hours and glutaraldehyde for 10 hours.
However, following these protocols is the exception and not the rule for most salons. Most only immerse the instruments in a hospital-based disinfectant (like chlorine or quaternary ammonium) for 10 minutes between customers.8 There are not enough state inspectors to monitor the enormous and ever-changing amount of salons in the U.S. to determine if they are following sanitation guidelines.8 Given the risk of developing infection, it is important that we recommend to the patients who still insist on receiving pedicures to purchase/bring their own instruments to the salon and avoid manipulation of the hyponychium and true cuticle.
In a spirit of “if you can’t beat them, join them,” many physicians are opening up medical-based pedicure salons adjacent to their practices or as included spaces in their practices. Employing nail technicians and using autoclaved instruments, these “medi-pedi” services have a physician on the premises and may be as pampering as a salon visit. However, they are ultimately safer infection-wise and for those who should avoid or those who are wary of receiving a general pedicure. These include patients with diabetes, immunocompromised patients, patients on blood thinners, etc. Medi-pedis may be dry (i.e. not utilizing a foot bath) or may utilize single-use liners for the water basin in a pipeless pedicure chair.
Do Gel Nails Pose Risks?
A trend that debuted on the market as Light Cured Nails (Wilde Cosmetics) in 1985 has become the industry standard due to their long wearing capability (two to four weeks) and chip/dent/scratch resistant shiny finish.2,9 There are now 46 brands of gel polish, which typically consist of ethyl cyanoacrylate and polymethyl-methacrylate monomers that are cured with either ultraviolet or light-emitting diode devices.2,9 Other names associated with gel nails include Shellac, Gelish, Gelac, etc.9
The procedure for applying a gel prosthesis to the nail is as follows: apply a primer solution to allow the gel layer to adhere to the nail plate. Next, one would apply the gel polish to the entire nail plate while avoiding the cuticle. One then cures this under a UV light for about two minutes. Applying a cleaning solution to the finalized gel nail removes any excess gel or residue after the curing process.
Gel nails have become popular not only for their durability but also for those who have nail dystrophy and want a different option than acrylic nails or nail enamel to camouflage the nail. Also, musicians who play string instruments or athletes who traumatize their feet daily have looked to gel nails as an option for cosmesis and protection.
As gel nails can assist to camouflage common nail dystrophies (pitting, Beau’s lines, onychorrhexis, onychoschizia) and create a cosmetically acceptable appearance, they can also cause damage to the nail plate upon their removal.2,10 For removal of the gel prosthesis, people must soak the nails in acetone for 10-15 minutes and even after that to peel off the remaining polish. In a case series by Chen and colleagues, people who removed their gel polish reported nail thinning and brittleness.10 These people then had ultrasound and reflectance confocal microscopy to verify nail plate changes. All had considerable thinning of the nail plate with brittleness and onychoschizia still present five weeks after removal.
Unfortunately, the general public is unaware of the possible damages to the nail plate from gel nails as well as the potential for contact dermatitis from the acrylate and/or acetone, and the possibility of developing paronychia, onycholysis and brittleness from the removal of the product.
Another consideration with gel nails is the use of the UVA devices to cure the gel polish. One study showed that the standard UVA nail lamp has two to four 9 W bulbs.11 Being exposed to this device once every two weeks for 10 minutes is equivalent to a person spending “1.5-2.7 minutes in sunlight each day” if considering UVA exposure and “17-26 seconds each day” if considering UVB exposure.11 Recommendations for our patients who regularly receive gel pedicures are to wear sunscreen and place a white cloth over hands or feet that are exposed to the lamp. The patient who is on any photosensitizing medication such as doxycycline should also be aware that onycholysis and skin sensitivity can occur upon exposure to the UV lamp.
Recognizing And Preventing Problems With Acrylic Nails
Acrylic nails or nail extensions can come either as a preformed piece of plastic glued to the nail plate or as a custom-made, “sculptured” acrylic extension to the natural nail.2 The protocol for applying an acrylic nail is as follows. Clean the nails and roughen them with a file or pumice stone. Apply an antifungal/antibacterial solution to minimize the risk of paronychia. Push back or trim the true cuticle. Fit a template beneath the nail plate edge where one will build the sculpted nail (or apply a cyanoacrylate glue and an artificial nail tip). Mix acrylic and apply it with a brush to cover the natural nail and the template to the desired length. The material then hardens and one sands it to a shine and finally applies nail polish.2,7
The bond between the acrylic and natural nail is extremely strong, and can cause onycholysis upon removal of the sculpted piece. Also, as the nail grows and natural wear occurs, one must care for the sculpted nail tip and add more polymer proximally to accommodate the new nail growth. This is called “filling.”2 If these nails do not have continual maintenance, one can remove them by soaking them in acetone. Damage to the nail plate is likely with acrylic nails. When there is over two to four months of wear, the underlying nail plate will become yellow and thin. Many salon technicians recommend three months of continual acrylic nail wear with one month off.2
As with the other nail cosmetics I have discussed, an issue with acrylic nails is allergic contact dermatitis, especially to the acrylate glues. Beyond a skin reaction due to the glue, authors have reported that an acrylate allergy induced by acrylic nails resulted in a knee replacement implant failure.12 The acrylic bone cement often used in these procedures can cross-react to the polymers used in nail cosmetics. It is important to get a thorough history and patch testing if a patient is a candidate for an orthopedic implant and has a history of fingernail or toenail sensitivity to a nail cosmetic.
Understanding The Health Care Risks With Nail Cosmetics
As healthcare workers, we are encouraged not to wear acrylic nail prostheses due to the possibility of the artificial nail harboring bacteria, thus transmitting infection from clinician to patient. There have been a number of studies trying to establish a link between artificial nails and the spread of infection.12 In 2009, the World Health Organization published guidelines stating that all artificial nails are prohibited in all direct patient care and healthcare workers should keep their nails short.13 The CDC also published a similar statement.14
With artificial nails, the acrylic monomers are highly permeable and allow an ideal environment for fungus and bacteria to grow. Also, as artificial nails grow age, they can lift at the edge, which provides a safe space for microorganisms to thrive. The aforementioned statements from the CDC and the World Health Organization are based on small studies showing that artificial nails had more bacteria on the surface than natural nails.15 However, these studies did not look at the proper hand washing hygiene that one employs prior to contact with a patient. McNeil and colleagues attempted to answer this question and found that after hand washing, cultures detected more microorganisms from an acrylic nail than a natural one.16
Artificial nails are not the only ones under attack from microorganisms. One study looked at the difference between freshly polished nails and those that had polish on for more than four days (with cracking, chipping, etc.).17 After a surgical scrub, more bacteria were present on nails with older polish than with fresh polish or natural nails. A Cochrane Review on this subject concludes that there is insufficient evidence on nail polish causing infection spread due to the lack of well-designed clinical trials.18
Overall, the use of nail polish and acrylic nails remains controversial. From the literature showing that pathogenic organisms are significantly higher in number in artificial nails, it seems reasonable to banish all acrylic nails not only from surgical settings but from inpatient and at-risk outpatient settings as well.15 Regarding nail polish, even with the inconclusive evidence, it makes sense to keep nails freshly polished and potentially ban its use in high-risk and sterile settings.
Also of note, if a patient presents to your office for a nail-based concern or any other skin concern, it is imperative that the nails be free of polish or any other cosmetic. Many nail dermatologists will have patients reschedule if the cosmetic is still present prior to the appointment. I will often recommend to patients with nail concerns that patients make the podiatric appointment prior to the scheduled salon service in order to avoid disappointment and feeling they have wasted money when I bring out the acetone in the treatment room to better visualize the nail unit. Patients often don’t realize that proper examination of the nail unit and possible burring of the nail plate must occur on a clean, polish-free nail.
Other Products That Can Assist With Cosmesis
Poly-ureaurethane 16% (Nuvail, Innocutis) is a prescription waterproof and flexible film that forms to the nail contour to provide protection from direct abrasion and optimal moisture balance to protect the nail from the effects of moisture.19 Nasir and colleagues followed 53 patients with nail dystrophy who used Nuvail nightly.20 Assessing for nail color, onycholysis and subungual hyperkeratosis, the study authors noted a 60 percent improvement after six months of using Nuvail.
I have used Nuvail to treat various forms of nail dystrophy: onycholysis, Beau’s lines, brittle nails and pitting. I will have patients use this product as a base coat if they desire nail polish use.
One may apply a podiatry-only office-based cosmetic, Keryflex nail resin (Pod-Advance), to camouflage and protect the nail unit. Keryflex can cover nail fungus and various other nail dystrophies whether or not the patient is receiving systemic treatment for the underlying condition. Keryflex has many uses, including application after laser treatment for onychomycosis and in covering a nail that has become dystrophic following surgery for paronychia.
It is important to note that even though the Keryflex protocol requires curing of the resin with a UV light, it is not a gel nail polish as people do not remove it with acetone and its durability is longer (six to 12 weeks in my experience). The resin grows out distally naturally with the nail and one removes this by mechanical means (nail debridement or burring). It is a three-step system. The patient would apply a non-odorous bond first and allow it to air dry for one to two minutes. Then one can follow this with a coating of the resin, a two-minute cure with a UV light and maybe a gloss coat. Keryflex is available as either a clear or opaque resin, and patients may use nail polish and nail polish remover on top of the Keryflex resin. Patients may apply the resin to a nail that is normal in length or apply it to create an illusion of a normal nail in one that has become atrophic by various means.
In the next year, there promises to be exciting advances that will meld the cosmetic and clinical treatment world in nails. In the meantime, the aforementioned products and services may serve as your guide to recognize complications (contact dermatitis, differential diagnoses of onychomycosis) and possible treatments and recommendations for nail conditions.
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 .
References 1. Nails Technician. Available at http://files.nailsmag.com/Market-Research/NAILSbb12-13stats.pdf .
2. Draelos ZD. Cosmetic treatment of nails. Clinics Derm. 2013; 31(5):573-577.
3. Available at www.julep.com/julep-plie-wand.html .
4. Available at www.sallyhansen.com/nails/nail-color/stickers/salon-effects-real-nail-polish-strips .
5. Scher RK. Cosmetics and ancillary preparations for the care of the nails. Composition, chemistry, and adverse reactions. JAAD. 1982; 6: 523-528.
6. Available at www.wellandgoodnyc.com/2012/10/16/a-new-era-of-super-clean-nail-polishes/ .
7. Dahdah MJ, Scher RK. Nail diseases related to nail cosmetics. Derm Clinics. 2006; 24(2):233-239.
8. Rich P. Nail cosmetics. Dermatol Clin. 2006; 24(3):393-399.
9. Nanda S, Grover C. Utility of gel nails in improving the appearance of cosmetically disfigured nails: experience with 25 cases. J Cutan Aesthet Surg. 2014; 7(1):26-31.
10. Chen AF, Chimento SM, Hu S, et al. Nail damage from gel polish manicure. J Cosmetic Derm. 2012;
11(1):27-29. 11. Jefferson J, Rich P. Update on nail cosmetics. Dermatologic Therapy. 2012. 25(6):481-490.
12. Haughton AM, Belsito DV. Acylate allergy induced by acrylic nails resulting in prosthesis failure. J Am Acad Dermatol. 2008; 59(5): S123-124.
13. Available at www.sgh.org.sa/sf/files/iche_who_hh_guidelines_july_09.pdf .
14. Available at www.cdc.gov/handhygiene/guidelines.html .
15. White J. Jewelry and artificial fingernails in the health care environment: infection risk or urban legend? Clinical Microbio Newsletter. 2013; 35(8):61-67.
16. McNeil SA, Foster CL, Hedderwick SA, Kauffman CA, et al. Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by healthcare workers. Clin Infect Dis. 2001; 32(3):367-372.
17. Wynd CA, Samstag DE, Lapp AM. Bacterial carriage on the fingernails of OR nurses. AORN J. 1994; 60(5):796, 799-805.
18. Arrowsmith V, Taylor R. Removal of nail polish and finger rings to prevent surgical infection. Cochrane Database Syst Rev. 2012; 5:CD003325.doi: 10.1002/14651858.CD003325.pub2 .
19. Nuvail PI, Innocutis. Available at http://innocutis.com/wp-content/uploads/2012/06/nuvail-pi_0612.pdf .
20. Nasir A, Goldstein B, van Cleff M, Swick L. Clinical evaluation of safety and efficacy of a new topical treatment for onychomycosis. J Drugs Dermatol. 2011; 10(10):1186-1191.
For further reading, see “How To Set Up A Cosmetic Care Room In Your Practice” in the April 2010 issue of Podiatry Today.