Modulation of linear nail growth to treat diseases of the nail

Unlocking potential: clinical benefits of enlarging the nail bed explored through continuous W-shaped incisions

PURPOSE

Nail bed atrophy, a common condition for which conservative treatments have limited efficacy, continues to present challenges in determining the optimal surgical intervention. This study introduces a novel technique for nail bed expansion.

MATERIALS AND METHODS

A total of 34 patients with nail bed atrophy, selected between 2015 and 2020 (ChiCTR2000036232), were randomized into a control group (n = 17) and a surgical group (n = 17). While no specialized treatment was administered to the control group, the surgical group underwent continuous W-shaped incisions on the ventral side of the digits.

RESULTS

Following a 12-month follow-up period, changes in nail bed height, width, area, esthetic satisfaction, pain levels, and tactile sensation were assessed in both groups. In the surgical group, the height, width, and area of the nail bed increased significantly by 1.50 ± 0.49 times, 1.16 ± 0.23 times, and 1.69 ± 0.60 times, respectively, compared to the preoperative measurements. The newly-formed nail plate exhibited improved esthetics, characterized by its smoothness and transparency, a marked improvement over the control group (p < 0.05). Furthermore, this surgical approach showed significant effects, regardless of whether it was applied to fingers or toes.

CONCLUSION

The continuous W-shaped incision technique demonstrated substantial benefits and could be a practical therapeutic approach for nail bed enlargement.

Follow-up of Favipiravir-Induced Nail Fluorescence: Implications for Nail and Drugs

INTRODUCTION

Favipiravir creates fluorescence on nails, which can be seen with Wood's light.

OBJECTIVES

The objectives of this study are to examine the properties of fluorescence in the nail due to favipiravir and to observe whether other drugs also produce fluorescence in the nail.

METHODS

The research is descriptive, prospective, and quantitative. This study recruited 30 healthcare workers who received favipiravir treatment and 30 volunteers who took or did not take any medication except favipiravir from March 2021 to December 2021. Fingernails of the patients and control groups were examined under Wood's light in the darkroom. If fluorescence was observed in the fingernails, we followed up once a month until the fluorescence disappeared. We calculated the nail growth rate by dividing the distance of nail fluorescence from the proximal nail fold by the number of days since favipiravir was started.

RESULTS

We found nail fluorescence in all patients receiving a loading dose of favipiravir. The fluorescence in the nail decreased and disappeared in the 3rd month. The average nail growth rate at the first visit was 0.14 mm/day. The nail growth rate at the second visit was 0.10 mm/day. A statistically significant difference was found between the first and second visit nail growth rates (z: -2.576; p=0.010<0.05). We found that other drugs did not produce any fluorescence in the nail.

CONCLUSIONS

Nail fluorescence induced by favipiravir is dose-dependent and decreases in intensity over time. Nail fluorescence due to favipiravir is likely due to the active ingredient of the drug.

Efinaconazole topical solution (10%) for the treatment of onychomycosis in adult and pediatric patients

Introduction: Onychomycosis, a common nail disorder caused by fungal infection, can be managed pharmaceutically with oral or topical treatments. While oral treatments are often used first-line to treat nail infections, these systemic antifungals are not appropriate for all patients, and no oral treatments are approved for use in children in the USA. Given this need, topical antifungals were developed, which can be used as monotherapy or in combination with oral drugs.Areas Covered: Efinaconazole 10% solution is an azole antifungal indicated for topical treatment of toenail onychomycosis in pediatric and adult patients. This qualitative literature review summarizes available chemical, pharmacological, efficacy, safety, and post-marketing surveillance data of efinaconazole 10% topical solution. Efinaconazole 10% has been shown to be safe and efficacious regardless of disease severity/duration at baseline; patient gender, ethnicity, or age (including pediatrics); or comorbidities such as diabetes or tinea pedis. Overall, efinaconazole is a safe and effective clinical option for the treatment and management of onychomycosis.Expert Opinion: Efinaconazole is the first new antifungal approved for onychomycosis in 10 years in the USA. It has comparable efficacy to systemic antifungal agents such as itraconazole, and a favorable adverse events profile with minimal systemic exposure and no drug-drug interactions.

Pathogenesis, Clinical Signs and Treatment Recommendations in Brittle Nails: A Review

Nail plate brittleness (or fragility) is a common complaint affecting up to 20% of the population, especially women over 50 years of age, with fingernail fragility being more prevalent than toenail fragility. Nail brittleness is characterized by nails that split, flake and crumble, become soft and lose elasticity. The main clinical presentations are: onychoschizia, onychorrhexis, superficial granulation of keratin and worn-down nails. According to causative factors, we can distinguish 2 forms of nail fragility (NF): a primary "idiopathic or brittle nail syndrome" form and NF secondary to different causes such as inflammatory nail disorders, infections, systemic diseases and general conditions, traumas and alteration of the nail hydration. Optimal management requires treatment of the primary cause of brittle nails, when possible. In idiopathic NF oral supplementation, vitamins (especially biotin, also known as vitamin B7), trace elements and amino acids (especially cysteine) have been reported to be useful. In addition, several products, such as topical moisturizers and lacquers could be considered to restructure the affected nail plate and to reduce psychological impacts of this common problem.

Biotin: overview of the treatment of diseases of cutaneous appendages and of hyperseborrhea

One of the most common micronutrient deficiencies with cutaneous findings is the vitamin B, also known as biotin, deficiency. Biotin deficiency may be due to congenital lack of biotinidase, or acquired following some conditions that interfere with its absorption, such as inflammatory bowel disorders, a diet too rich in avidin, magnesium deficiency, smoking habit and treatment with broad-spectrum antibiotics, anticonvulsants and sulfonamides. This review highlights the role of biotin in the most common skin disorders such associated with biotin deficiency and an approach to their treatment. Biotin administration may improve the treatment of hair loss when deficiency is detected on the basis of a careful patient history, clinical examination and the determination of serum biotin levels. The use of biotin is rationale in seborrheic dermatitis as the vitamin intercepts the main metabolic pathways underlying the pathogenesis of the disease. Treatment with biotin could also be useful in comedonal acne characterized by a high rate of seborrhea, and may be helpful for acne treated with topical retinoids, contributing to the control of flaking and irritation. The tolerability of biotin is excellent and there is no risk of hypervitaminosis even in the case of high doses. It is important that administration is controlled by physicians and follows a medical diagnosis and prescription. Correct doses used in dermatological conditions are safe and are not at risk of interference with laboratory tests.

Onychomycosis in Athletes

Onychomycosis is a common disorder that is difficult to cure. Prevalence is lower in children (0.7%), but athletes are 2.5-fold more likely to develop the disease, with infections of the toenails seven times more prevalent than those of the fingernails. This is a concern for athletes as it can interfere with their performance. The risk of developing onychomycosis is increased by the warm environment of many sports activities; the use of occlusive footwear; the warm, moist environment associated with socks and sweating; shared, close quarters among athletes; and trauma to the foot and toenail. Once infected, onychomycosis treatment requires a long duration of treatment with strict compliance, a potential problem for younger patients. Treatment carries the risk of significant side effects, and recurrence rates remain high. Avoiding infection can be a potent first line of defense and may circumvent the need for treatment. Preventive recommendations such as keeping toenails short and proper washing of laundry, to name a few, can be effective and are discussed here. Technological improvements such as synthetic, moisture-wicking socks and well-ventilated, mesh shoes have also been shown to reduce moisture and injury. Education about preventing fungal spread and improving hygiene in the locker room, gym, and pool are of critical importance. This overview of onychomycosis focuses primarily on the preventive measures and innovative changes in athletic gear. It also provides a compact step-by-step guide to prevention intended to be useful for both the general public and the professional. It can be reproduced to use as a handout for athletes, trainers, and coaches.

A Week of Oral Terbinafine Pulse Regimen Every Three Months to Treat all Dermatophyte Onychomycosis

Terbinafine has proved to treat numerous fungal infections, including onychomycosis, successfully. Due to its liver metabolization and dependency on the cytochrome P450 enzyme complex, undesirable drug interaction are highly probable. Additionally to drug interactions, the treatment is long, rising the chances of the appearance of side effects and abandonment. Pharmacokinetic data suggest that terbinafine maintains a fungicidal effect within the nail up to 30 weeks after its last administration, which has aroused the possibility of a pulse therapy to reduce the side effects while treating onychomycosis. This study's goal was to evaluate the effectiveness of three different oral terbinafine regimens in treating onychomycosis due to dermatophytes. Sixty-three patients with onychomycosis were sorted by convenience in three different groups. Patients from group 1 received the conventional terbinafine dose (250 mg per day for 3 months). Group 2 received a monthly week-long pulse-therapy dose (500 mg per day for 7 days a month, for 4 months) and group 3 received a 500 mg/day dose for 7 days every 3 months, totaling four treatments. There were no statistical differences regarding the effectiveness or side effects between the groups. Conclusion: A quarterly terbinafine pulse regimen can be a possible alternative for treating onychomycosis caused by dermatophytes.

Innovations in biological assessments of chronic stress through hair and nail cortisol: Conceptual, developmental, and methodological issues

Much of the existing research on biological mechanisms underlying the stress experience has focused largely on moment-to-moment stress, rather than on chronic stress, an arguably more powerful predictor of long-term outcomes. Recent methodological innovations have paved the way for new lines of research on chronic stress, with promising implications for developmental researchers and for those who study health and adversity. In particular, there are increasing studies that have focused on chronic stress assessments by relying on cortisol derived from hair and nails as a biomarker for chronic stress. In this paper, we provide an overview of their use, describe how hair and nail cortisol ought to be conceptualized differently across the lifespan, how developmental factors may impact its interpretation, and the circumstances under which its use may be more methodologically sensible. The purpose of this review is to provoke further discussion and encourage careful research designs that utilize hair and nail cortisol for understanding the effects of chronic stress exposure from the early developmental period, across adverse contexts, and in association with psychological and physical health outcomes.

Onychomycosis: Treatment and prevention of recurrence

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily living, and impair social interactions. The epidemiology, risk factors, and clinical presentation and diagnosis of onychomycosis were discussed in the first article in this continuing medical education series. In this article, we review the prognosis and response to onychomycosis treatment, medications for onychomycosis that have been approved by the US Food and Drug Administration, and off-label therapies and devices. Methods to prevent onychomycosis recurrences and emerging therapies are also described.

Oral antifungal medication for toenail onychomycosis

BACKGROUND

Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence-based choice for treatment.

OBJECTIVES

To assess the effects of oral antifungal treatments for toenail onychomycosis.

SEARCH METHODS

We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies.

SELECTION CRITERIA

RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years.We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high-risk domain was 'blinding of personnel and participants'.We found high-quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine-treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate-quality evidence).There was high-quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu-like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate-quality evidence).Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low-quality evidence).There is moderate-quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate-quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low-quality evidence). Common adverse events in both groups included headache, viral infection, and nausea.Moderate-quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate-quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin-treated participants) along with nausea and vomiting (in azole-treated participants). Very low-quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants).There is low-quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low-quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin-treated participants) as well as taste loss and nausea (in terbinafine-treated participants). No studies addressed recurrence rate for this comparison.No study addressed quality of life.

AUTHORS' CONCLUSIONS

We found high-quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate-quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate-quality evidence).Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate-quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low-quality evidence).Only four comparisons assessed recurrence rate: low-quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them.Only a limited number of studies reported adverse events, and the severity of the events was not taken into account.Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding.

Nail abnormalities associated with systemic pathologies

Nail abnormalities can arise in conjunction with or as a result of systematic pathologies. These pathologies include single-organ diseases, multisystemic diseases, and drug-induced insults. Clinical signs associated with these conditions include dyschromias, vascular alterations, periungual tissue changes, textural dystrophies, contour alterations, and growth-rate alterations. The associated systemic pathologies may affect any part of the nail apparatus, including the nail matrix, the nail plate, the nail bed, the underlying vasculature, and the periungual tissues. The anatomical location and extent of damage determine the clinically manifested anomaly.

Thermal characterization in vitro of human nail: photoacoustic study of the aging process

In the present work, the rear photoacoustic signal technique is used to determine thermal properties of human nails. The aging process of the human nail is analyzed through its thermal diffusivity and specific heat and using these results, thermal conductivity and thermal effusivity is determined. The study in vitro of this natural polymer showed a minimum for thermal properties to age about 20 years and an increase and possible saturation of them for ages over 50 years. The minimum value found for thermal diffusivity was close to 10x10(-4) cm2 s(-1) with saturation near 18x10(-4) cm2 s(-1). Thermal conductivity and effusivity presents the same behavior.

Onychomycosis: diagnosis and definition of cure

Until now, there has been no agreement on criteria defining resolution of onychomycosis. Most published reports use clinical and mycological cure, which comprises a completely normal-appearing nail plate, and negative nail culture and microscopy results, as the end point for defining success of therapeutic intervention. Reported here is the definition of onychomycosis, which delineates both primary and secondary criteria for diagnosis of onychomycosis and identifies clinical and laboratory parameters to define a resolved fungal nail infection. Onychomycosis cure is defined by the absence of clinical signs or the presence of negative nail culture and/or microscopy results with one or more of the following minor clinical signs: (1) minimal distal subungual hyperkeratosis; and (2) nail-plate thickening. Clinical signs indicative of persistent onychomycosis at the end of the observation period include (1) white/yellow or orange/brown streaks or patches in or beneath the nail plate; and (2) lateral onycholysis with subungual debris. Although nail appearance will usually continue to improve after cessation of therapy, the nails may have a persistent abnormal appearance even in cases where treatment has been effective.

Brittle nail syndrome: a pathogenesis-based approach with a proposed grading system

Brittle nail syndrome is a heterogeneous abnormality, characterized by increased fragility of the nail plate. Brittle nails affect about 20% of the population and women are affected twice as frequently as men. The vast majority of patients experience brittle nails as a significant cosmetic problem and a substantial number indicate that these nail abnormalities are painful, impair daily activities, and may have a negative impact on occupational abilities. Pathogenic factors leading to brittle nails are factors that impair intercellular adhesion of the corneocytes of the nail plate or factors that cause a pathologic nail formation by involving the matrix. Clinical features of brittle nail syndrome are onychoschizia and onychorrhexis: the impairment of intercellular adhesive factors of the nail plate is expressed as onychoschizia, whereas the involvement of the nail matrix is expressed as onychorrhexis. Although impairment of life quality has not been evaluated for patients with brittle nail syndrome, the reduction of life quality in other nail problems has been studied and is evident. A proposed scoring system of key features of brittle nails is presented, and therapeutic approaches focussed on the pathogenic factors are discussed.

Nail Diseases Related to Nail Cosmetics

The use of nail care products and procedures to beautify and groom the nails is extremely common. Unfortunately, when improperly used, nail cosmetics can lead to nail diseases, such as paronychia, onycholysis, and brittle nails. Understanding the pathophysiology behind these conditions is an essential step toward better treatment and future prevention allowing patients to enjoy nail adornments while maintaining healthy nails.

Treatment of onychomycosis with oral antifungal agents

Onychomycosis is the most common nail disease and describes the invasion of the nail by fungi. Different clinical patterns of infection depend on the way and the extent by which fungi colonise the nail: distal subungual onychomycosis, proximal subungual onychomycosis, white superficial onychomycosis, endonyx onychomycosis and total dystropic onychomycosis. The type of nail invasion depends on both the fungus responsible and on host susceptibility. Treatment of onychomycosis depends on the clinical type of the onychomycosis, the number of affected nails and the severity of nail involvement. The goals for antifungal therapy are mycological cure and a normal looking nail. In this paper the treatment of onychomycosis with oral antifungal agents will be reviewed.