Risk factors for infection following ingrowing toenail surgery: a retrospective cohort study.

BACKGROUND: Ingrowing toenails are a common and painful condition often requiring surgical management. Practitioners who perform surgery on ingrowing toenails include orthopaedic surgeons, general practitioners, podiatrists and podiatric surgeons. There has been limited investigation into the specific surgical approaches used by Australian podiatric surgeons for ingrowing toenails, or the associated infection rates for these procedures. The aim of this study was to assess the frequency and type of ingrowing toenail surgery performed by podiatric surgeons, and identify risk factors for post-operative infection. METHODS: Data was entered into the Australian College Podiatric Surgeons (ACPS) National Audit Tool for all patients who underwent foot and ankle surgery performed by podiatric surgeons in Australia between January 2014 and December 2017. Infection within the first 30 days following surgery was recorded according to the ACPS national audit descriptors. Infection rates, risk ratios (RR) and 95% Confidence Intervals (CI) were calculated to determine postoperative infection risk. RESULTS: Of 7682 records, 1831 reported 2712 diagnoses of ingrowing nails. Patients with a diagnosis of ingrowing toenails were younger, less likely to have systemic disease, and a lower proportion were female compared to those without ingrowing toenails. Furthermore, they were more likely to be diagnosed with a post-operative infection than those without ingrowing toenails (RR = 2.72; CI = 2.00-3.69; P < 0.01). Univariate risk factors for post-operative infection following ingrowing toenail surgery include age greater than 60 years (RR = 3.16; CI = 1.53-6.51; P < 0.01), surgery performed in an office setting (RR = 1.77; CI = 1.05-2.98; P = 0.04), and radical excision of toenail bed procedure (RR = 2.35; CI = 1.08-5.01; P = 0.04). Patients that underwent radical excision or office based procedures were on average older, and more likely to have systemic disease. Further, radical excision procedures were more likely to be performed in office base settings. CONCLUSIONS: Ingrowing toenail surgery carries a greater risk of postoperative infection than other procedures performed by podiatric surgeons. Radical excision of toenail bed was associated with higher postoperative infection rates compared to other ingrowing toenail procedures. Procedures performed in an office setting carry a higher risk of infection. Further research into these associations is recommended.

The effect of oral hydrolyzed eggshell membrane on the appearance of hair, skin, and nails in healthy middle-aged adults: A randomized double-blind placebo-controlled clinical trial.

BACKGROUND: Many over the counter and consumer packaged goods are promoted to enhance the appearance of hair, skin, and nails for the consumer. Nutrition is a major factor in affecting the health and appearance of hair, skin, and nails. In addition to how one eats, dietary supplementation may play a role in overall health and in the physical appearance. AIMS: It was the aim of this study to objectively and subjectively evaluate the impacts of a nutritional intervention as compared to placebo on the appearances of hair, skin, and nails in healthy middle-aged adults. METHODS: Randomized, double-blind placebo-controlled study with 88 subjects randomized evenly to Study Product (BiovaBio™ 450 mg/d, n = 44) or Placebo (n = 44) for 12-weeks. Outcome tests included TrichoScan HD (hair), Canfield Visia® -CR (skin), modified FACE-Q (skin), and anchored Likert Scales (nails). RESULTS: Oral hydrolyzed eggshell membrane ingestion was associated with a significant improvement in facial skin appearance in crow's feet in 4 weeks and skin tone in 8 weeks, with significant impact on hair thickness, reduction in hair breakage and improvement in hair growth at 4, 8, and 12 weeks. There were no observed subjective improvements for nails (appearance, strength or growth). CONCLUSIONS: Oral supplementation of 450 mg/d hydrolyzed eggshell membrane for 12 weeks is associated with improvement in the appearance of facial skin and hair.

Modified single pedicle reverse adipofascial flap for fingertip reconstruction.

BACKGROUND: Homodigital adipofascial flap is a well-established method for treating a distal fingertip defect; nonetheless, its use has some limitations. Reconstruction of fingertip injuries, with radial or ulnar tissue loss, may lead to some difficulties in providing an adequate bone coverage. The standard bipedicled technique did not allow the flap to cover the bone exposure without excessive tension. In our series, the reverse adipofascial flap had a single pedicle. The modified technique, because of its improved degree of rotation, granted the flap to reach either radial or ulnar tissue losses. PATIENTS AND METHODS: We treated 15 fingertip amputations distal to the lunula (9 Allen's type II and 6 type III), the mean size of defects was 2.7 cm2 (range, 1.8-3.2 cm2 ), the mean age of patients was 44 years (range, 22-63 years). Quick Disabilities of the Arm, Shoulder, and Hand score and Visual Analogue Scale were evaluated along with a 2-point discrimination test; the aesthetic satisfaction of the patients was estimated subjectively using a 5-point Likert scale. RESULTS: Mean flap size was 3.6 cm2 (range, 2.5-4.2 cm2 ), primary flap survival was observed in 14 out of 15 cases, partial flap necrosis was observed in 1 case, the nail grew in all fingers in about 6 months. Mean proximal and distal interphalangeal joint motion was 89° (range, 80°-100°) and 71° (range, 65°-80°), respectively. No complications were observed at the donor site. The median static 2-point discrimination was 4.5 mm (range, 3-8 mm), the mean quick DASH score was 2.6 (range, 0-9.1). All patients returned to work within a mean of 4.4 weeks (range, 4-5 weeks). The follow-up was 12 months. CONCLUSIONS: Single pedicle reverse adipofascial flap is an effective technique. This modified procedure allows a wider degree of flap rotation; it represents the ultimate arrow in our bow to address some particular defect geometry.

Morphology, growth rate, and thickness of the nail plate during the pregnancy.

Pregnancy causes some physiological skin changes, such as hyperpigmentation and striae gravidarum. Thickening of scalp hair and a prolonged anagen phase are also known to occur during pregnancy. However, a limited number of studies have been conducted on the effect of pregnancy on the nails. We aimed to investigate the effect of pregnancy on the morphology of the nail plate, specifically its growth rate and thickness. Pregnant women and a control group consisting of healthy female volunteers were included in the study. The distance from the apical point of the lunula to the midpoint of the free edge of the nail plate of the the thumb was measured with digital calipers. The measurement was repeated during the control visits and recorded in millimeters per day. The thickness of the nail plate of the thumb was measured at the midpoint of the free edge of the nail plate. A dermatological examination of the fingernails was performed for both groups. A survey was also conducted to identify any changes that occurred in the nails during pregnancy. The mean growth rate of the nail plate in pregnant women was 0.1 ± 0.05 mm/day, and in the control group it was 0.09 ± 0.05 mm/day. There was no statistically significant difference between the pregnant and control groups regarding the growth rate of the nail plate (P = 0.438). The mean thickness of the nail plate in pregnant women was 0.87 ± 0.19 mm, and in the control group it was 0.75 ± 0.17 mm. There was a statistically significant difference between the groups with respect to nail plate thickness (P < 0.001). A dermatological examination of the fingernails in the two groups did not reveal any statistically significant differences with respect to the nail findings. We determined in our study that pregnancy did not affect the growth rate and the morphology of the nails but increased the thickness of the nail plates.

The effect of cutaneous prostaglandin application on nail growth, nail brittleness, and intraocular pressure.

BACKGROUND: Bimatoprost has known adnexal activity and was observed to increase nail growth at two clinical centers. OBJECTIVES: In this randomized, double-blinded, placebo-controlled pilot study, we examine the effect of bimatoprost (Lumigan 0.01%), applied bid to the proximal nail fold on nail growth, nail brittleness, and intraocular pressure. METHODS: Bimatoprost drops were placed on the proximal nail folds of 45 subjects on one hand (medication group) and vehicle drops to the other hand (control group). Baseline and final nail growth measurements, Goldmann applanation tensions of both eyes, and photos at 30 days were performed. Nail brittleness was subjectively graded. RESULTS: For the 38 subjects completing the study, the final mean nail growth of the hands, the net individual nail growth of the digits (excluding chipped nails), nail brittleness, and eye pressure readings were NS at P<.05. Photos revealed no increased hirsutism, but one subject with increased skin pigmentation. The drops were well tolerated without adverse effects. Nail chipping was a limitation of the study. CONCLUSIONS: Despite the negative results in this pilot study on nail growth and brittleness, further studies with higher bimatoprost concentration (0.03%) are warranted. We recommend monitoring nail growth by etching or marking the nail rather than measuring the full nail length due to our chipped nail findings.

Oral supplementation with specific bioactive collagen peptides improves nail growth and reduces symptoms of brittle nails.

BACKGROUND: Brittle nail syndrome is a common problem among women and refers to nails that exhibit surface roughness, raggedness, and peeling. AIM: The goal of this study was to investigate whether daily oral supplementation with collagen peptides alleviates the symptoms of brittle nails and improves nail growth rate. METHODS: In this open-label, single-center trial, 25 participants took 2.5 g of specific bioactive collagen peptides (BCP, VERISOL® ) once daily for 24 weeks followed by a 4-week off-therapy period. Nail growth rate and the frequency of cracked and/or chipped nails as well as an evaluation of symptoms and global clinical improvement score of brittle nails were assessed by a physician during treatment and 4 weeks after discontinuation. RESULTS: Bioactive collagen peptides treatment promoted an increase of 12% nail growth rate and a decrease of 42% in the frequency of broken nails. Additionally, 64% of participants achieved a global clinical improvement in brittle nails, and 88% of participants experienced an improvement 4 weeks post-treatment. The majority of participants (80%) agreed that the use of BCP improved their nails' appearance, and were completely satisfied with the performance of the treatment. CONCLUSIONS: This study demonstrated that the daily ingestion of BCP increased nail growth and improved brittle nails in conjunction with a notable decrease in the frequency of broken nails.

The use of topical minoxidil to accelerate nail growth: a pilot study.

Linear nail growth rate is affected by various conditions, one of which is the level of blood flow. Our supposition was that topical minoxidil, which has vasodilatory properties, can increase the rate of nail growth. The aim of this study was to determine the impact of topical minoxidil on nail growth. A 5% topical minoxidil solution was applied twice daily to the fingernails of 32 participants. Two groups of 16 participants were randomly chosen. In one group, the applications were made to the right index and left ring fingernails, and, in the other, the left index and right ring fingernails. During each visit (weekly during the first month and every 2 weeks during the second month), the nail length of six fingernails (index, middle, and ring of both hands) was measured using a digital caliper. Beginning in the first week, the mean nail length of the treated nails was greater than that of nails in the untreated group with statistical significance. There were no systemic or cutaneous side effects. During the first month, the mean growth of the treated nails was 4.27 mm/month compared with 3.91 mm/month in the untreated nails (P = 0.003). These findings suggest that a 5% concentration of topical minoxidil can stimulate nail growth with increased growth beginning in the first week of application. The results may have important implications for the treatment of nail disorders; however, a comparable study involving participants with nail disorders is highly recommended.

Response of Fingernail Growth to Out-of-Field Low-Dose X ray in Cancer Patients Receiving Radiotherapy.

The entire body of a patient with cancer is exposed to low-dose levels of radiation (mGy) during radiation therapy. The safety and biological impact of such exposure to low-dose radiation on the human body are largely unknown. The fingernail is a highly proliferative tissue, and its growth can be monitored during radiation treatment to analyze early effects of low-dose radiation. The fingernails of 30 patients who received external beam radiotherapy (EBRT) were used in this study to investigate the change in nail growth during fractionated radiotherapy. Lead shields were applied to some fingers to create dose variance within individual patients. The absorbed dose was measured, and the relationship between the dose and change in nail growth rate was analyzed. Other factors, including serum albumin, hemoglobin level, body weight index, age, gender and chemotherapy, were also subjected to multivariate analysis. Fingernails from patients received an average of 0.96 mGy per treatment fraction. We observed a surprising decline in fingernail growth rate during radiotherapy, which was more prominent in the nonshielded fingernails with a relatively high-absorbed dose. Such growth delay could be observed as early as one week postirradiation and lasted the entire treatment course. Using fingernail growth as a novel marker for radioresponse, the current study showed that exposure to very low-dose ionizing radiation has previously unrecognized early effects on human tissue.

Accelerated nail growth rate in HIV patients.

BACKGROUND: Many factors have been noted to alter the growth rate of both finger and toe nails, some with harder evidence than others. Infectious diseases are among the ones reported as slowing the growth rate. However, on previous studies we noticed that patients living with HIV and onychomycosis could be cured without the use of antifungal therapy, only with the immunological improvement provided by the combined antiretroviral therapy, and we wanted to prove that the growth rate is also increased in this group and thus probably contributes to the cure of onychomycosis. METHODS: This was an observational, descriptive, and prospective study. We marked with a scalpel the nail plate of the first finger of the non-dominant hand and the same foot, and measured the nail growth in the subsequent medical appointments with a magnifying glass and a millimetric scale. RESULTS: Thirteen patients completed the study, and were paired with healthy controls by age and gender. After performing Mann-Whitney U test, our results showed statistical significance among both groups, showing that patients with HIV have faster nail growth rates than those in the HIV negative group. CONCLUSIONS: There is little data on HIV nail growth rate to compare our results, but what we see in the clinical practice is that this group of patients shows a faster nail growth rate, as has also been reported for longer eyelashes, and this could be an important factor in the cure rates of onychomycosis.

Genetics of syndromic and non-syndromic hereditary nail disorders.

The nail is a unique epithelial skin appendage made up of a fully keratinized nail plate. The nail can be affected in several systemic illnesses, dermatological diseases, and inherited nail disorders. Nail dystrophies can present as isolated disorders or as a part of syndromes. Substantial progress has been achieved in the management and diagnosis of nail diseases; however, not much is known about the underlying molecular controls of nail growth. The homeostasis and development of the nail appendage depend on the intricate interactions between the epidermis and underlying mesenchyme, and comprise different signaling pathways such as the WNT signaling pathway. Digit-tip regeneration in mice and humans has been a known fact for the past six decades; however, only recently the underlying biological mechanisms by which the nail organ achieves digit regeneration have been elucidated. Moreover, significant progress has been made in identifying nail stem cells and localizing stem cell niches in the nail unit. More fascinating, however, is the role they play in orchestrating the processes that lead to the regeneration of the digit. Further elucidating the role of nail stem cells and the signaling pathways driving epithelial-mesenchymal interactions in the nail unit might contribute to the development of novel therapeutic tools for amputees.

Combination therapy for onychomycosis using a fractional 2940-nm Er:YAG laser and 5 % amorolfine lacquer.

Onychomycosis remains difficult to cure by traditional methods. The aim of this study was to evaluate the efficacy of combination therapy with a fractional erbium yttrium aluminum garnet (Er:YAG) laser and 5 % amorolfine lacquer on onychomycosis. Nine patients with bilateral nails affected by distal and lateral subungual onychomycosis were included. The bilateral nails of each patient were divided into two groups. The 20 affected nails on one side of each patient as group 1 were treated with a fractional Er:YAG laser once a week and 5 % amorolfine lacquer twice weekly, while the 20 nails on the symmetrical side of each patient as group 2 were treated with amorolfine lacquer only. The laser treatment was conducted at weeks 1, 2, 3, 4, 8, and 12 in group 1. The clinical improvement, onychomycosis severity index (OSI), maximum linear clear nail growth (MLCNG), and mycological cure rate were evaluated. At week 24, 18 of 20 (90 %) nails in group 1 had achieved obvious clinical responses. The mean OSI score showed a significant decrease (5.24) and the average MLCNG was 3.1 mm in group 1. At week 24, 15 of 20 (75 %) nails achieved a negative mycological examination in group 1, compared with four of 20 (20 %) nails in group 2. The treatments were well-tolerated by most patients. This clinical study suggests that combination therapy of a fractional 2940-nm Er:YAG laser and 5 % amorolfine lacquer is an effective, safe, and convenient treatment method for onychomycosis.

Managing Assessments and Expectations: Patient Responses Following Therapy With Efinaconazole Topical Solution, 10%.

INTRODUCTION: Successful treatment of onychomycosis is both a clinical and therapeutic challenge. Effective patient education and reassurance are critical. This post hoc analysis aims to provide some guidance to physicians based on initial disease severity and influencing factors. METHODS: A post hoc analysis of two multicenter, randomized, double-blind, vehicle-controlled studies evaluating the efficacy and safety of efinaconazole topical solution, 10% in mild to moderate onychomycosis. Outcomes were assessed based on baseline severity (20%-29%, 30%-39%, 40%-49%, and ≥50% affected target toenail). RESULTS: Overall, the mean percent affected toenail following efinaconazole treatment decreased from 36.4% to 20.6% (a 43% reduction). The percent reduction in mean percent affected toenail (range, 43.6% to 59.8%) with efinaconazole was similar irrespective of baseline severity. Improvement was only seen in the very mildest patients with vehicle and not before week 36. Improvement was influenced by gender (females did better) and disease duration (long standing disease responding less well). CONCLUSIONS: Our onychomycosis patients treated with efinaconazole might expect a 50% improvement in their disease within a year, and this will be seen as significant by many, especially those who have suffered for many years. Many will do better, but they will need to be reminded of the slow growth of the toenail.

Physics of nail conditions: why do ingrown nails always happen in the big toes?

Although surgical treatment of nail conditions can be traced back centuries to the writings of Paul Aegineta (625-690 AC), little is known about the physical laws governing nail growth. Such a poor understanding together with the increasing number of nail salons in the high street should raise legitimate concerns regarding the different procedures applied to nails. An understanding of the physics of nail growth is therefore essential to engage with human medicine and to understand the aetiology of nail conditions. In this context, a theory of nail plate adhesion, including a physical description of nail growth can be used to determine the transverse and longitudinal curvatures of the nail plate that are so important in the physical diagnosis of some nail conditions. As a result physics sheds light on: (a) why/how nails/hooves adhere strongly, yet grow smoothly; (b) why hoof/claw/nail growth rates are similar across species; (c) potential nail damage incurred by poor trimming; (d) the connection between three previously unrelated nail conditions, i.e. spoon-shaped, pincer and ingrown nails and; last but not least, (e) why ingrown nails occur preferentially in the big toes.

Desenvolvimento do sistema tegumentar em bovinos com idades gestacionais estimadas de 20 a 140 dias / Development of the integumentary system in bovine with estimated gestational ages from 20 to 140 days

A pele representa parte importante do sistema tegumentar, pois desempenha funções como a proteção contra desidratação, lesões e infecções, além de apresentar alto poder de renovação. Histologicamente, a pele consiste de duas camadas funcionais, morfologicamente distintas, a epiderme e a derme. As glândulas mamárias, capsula ungueal e cornos também fazem parte deste sistema. Devido à escassez de dados na literatura sobre o desenvolvimento da pele e dos anexos de natureza córnea em bovinos, o objetivo deste trabalho foi descrever as características morfológicas do desenvolvimento do sistema tegumentar durante os períodos embrionário e fetal em bovinos. Os indivíduos foram divididos em três grupos: Grupo I -embriões de 20-26 dias (n=4); Grupo II -embriões 30-47 dias (n=6) e Grupo III -fetos de 74-140 dias (n=6). Durante o desenvolvimento da pele observou-se diferentes padrões morfológicos de acordo com as regiões analisadas, apresentando índice maior de diferenciação no intervalo entre 30-47 dias de gestação. O aparelho ungueal e a glândula mamária se desenvolvem mais tardiamente entre os dias 74-140 da gestação. Em resumo, estes resultados acerca do desenvolvimento do sistema tegumentar em bovinos, poderão auxiliar na interpretação e compreensão da formação dos órgãos que o constituem, assim como para a compreensão de alterações patológicas associadas à organogênese.

The skin is an important part of the integumentary system, which has important functions such as protection against dehydration, injury and infection, as well as present high potential of renewal. Histologically, the skin consists of two functional layers, that are morphologically distinct, the epidermis and dermis. The mammary glands, ungueal capsule and horn are also part of this system. Due the poor data available on literature about the development of skin and other cornea attachments in bovine, the aim of this study was to describe the morphological characteristics of the integumentary system development during the embryonic and fetal periods in bovine. Individuals were allocated in three groups: Group I -embryos from 20 to 26 days (n=4), Group II -embryos from 30 to 47 days (n=6) and Group III -fetuses from 74 to 140 days (n=6). During the development of the skin it was observed different morphological patterns according to the analyzed regions. Especially, a higher level of differentiation was observed during 30-47 days of gestation. The bovine claw and mammary gland develop later between 74 to 140 days of gestation. In summary, these results related to the development of the integumentary system in bovine may help the analysis and understanding of the development of their organs, as well as the pathological disorders associated to the organogenesis.

Nail disorders in infants and children.

PURPOSE OF REVIEW: Nail diseases in infants and children are an uncommon cause of consultation and are often difficult to diagnose and to manage. This review will cover nail diseases that are most commonly seen in clinical practice, including congenital and hereditary disorders and inflammatory, infective, and neoplastic nail diseases. The purpose of the review is to help the reader to recognize nail disorders at an early age and to manage them appropriately. RECENT FINDINGS: Two recent large studies have reported the clinical findings of genetic disorders involving the nails, that is, pachyonychia congenita and epidermolysis bullosa. Only a few articles gave a comprehensive review of a disease, as occurred for onychomycosis, while the majority of the reports published in the recent literature involve single cases. SUMMARY: Nail diseases in children and neonates are not easy to diagnose by nonexperts. Basic knowledge of the anatomy and biology of the nail facilitates their diagnosis as the understanding of their pathophysiology. This review gives hints at the most common nail diseases that affect infants and children.

Chevron nails: a normal variant in the pediatric population.

A 7-month-old girl was evaluated for V-shaped ridging of the fingernails consistent with chevron nails. Chevron nails are a normal variant in the pediatric population that is frequently outgrown. This case nicely demonstrates this normal finding that has so rarely been reported in the literature.