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The main nail problems encountered in general practice are trauma, onychomycosis, infection, ingrowing toenails, paronychia and psoriasis. Damage to the nail from trauma or disease results in nail dystrophy. The problem of nail changes due to onychotillomania, be it from excessive nail biting, picking or cleaning, should be suspected from the history and examination. Enquire whether the hands are frequently used in wet work or dirt. Look for associated skin disease (e.g. psoriasis, atopic dermatitis, lichen planus).
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Refers to the separation of the nail plate from the underlying nail bed and is a sign rather than a disease. This separation creates a subungual space with an air interface that gathers unwanted debris, such as dirt and keratin.
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Self-induced trauma is a common cause from obsessive manipulation, inc. meticulous cleaning and frequent manicuring.
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The band of discolouration at the base of the separated nail is usually in a straight line compared with other causes such as psoriasis and tinea. Tinea may be distinguished from other causes by white or yellow streaks or ‘spears’ travelling proximally in the nail.
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Greenish discolouration indicates invasion by Pseudomonas pyocynae or Aspergillus.
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First exclude psoriasis, tinea (check toe webbing) and trauma (check history).
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Keep nails as short as possible.
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Avoid insertion of sharp objects under nails for cleaning out debris.
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Apply tape (micropore or similar) over free edge for months, until healed.
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Avoid unnecessary soaps and detergents—wear gloves for housework, gardening, etc.
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Keep hands out of water.
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Use a mild soap and shampoo.
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First-line treatment esp. if mild—vinegar soaks, 10 min bd
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Pharmaceutical treatment
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This is fungal nail infection that mainly affects toenails. The most common form is distal lateral subungual caused by Trichophyton sp. A superficial white onychomycosis with distinct edges is also common. C. albicans and other moulds are not a common factor. Diagnosis is by culture and histology of the distal nail plate clippings placed in formalin. For more details on treatment see under tinea unguium. The treatment of choice for all types is oral terbinafine 250 mg (o)/d for 6 wks (cures 70–80%).
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Onychogryphosis, or irregular thickening and overgrowth of the nail, is commonly seen in the big toenails of the elderly and appears to be related to pressure from footwear. It is really a permanent condition. Simple removal of the nail by avulsion is followed by recurrence some months later. Permanent cure requires ablation of the nail bed after removal of nail. Two methods of nail ablation are:
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These are age related and are usually caused by local physical factors, such as repeated water immersion, and exposure to chemicals, such as detergents, alkalis and nail polish removers. Systemic causes such as deficiency of iron and vitamins are not considered to be a common factor.
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Avoid excessive hydration and trauma.
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Wear rubber gloves with cotton liners for wet work.
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Massage Vaseline or nail creams (e.g. Eulactol or Neostrat) into the nail several times daily.
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Nail polishes and hardeners (preferably without formalin) may give a good cosmetic result.
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Nail apparatus melanoma
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Responsible for 2–3% of all melanoma
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All age groups but esp. in 7th decade
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Presents as a longitudinal pigmented streak in the nail
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Usually diagnosed late
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Mortality >50%
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Early recognition may result in a cure
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All cases require a longitudinal nail biopsy for diagnosis
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If confirmed treatment is based on Breslow thickness and level of invasion
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Level 1 or in situ–removal of whole nail apparatus
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Invasive melanoma—amputation of distal phalanx
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Methods to release blood in the acute injury phase include:
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drilling a hole by twisting a standard hypodermic needle
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using the red hot end of an extended paper clip
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piercing with the hot wire of an electrocautery unit
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Penetration must be as superficial as possible.
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Advise the patient that the nail will eventually separate and a normal nail will appear in 6–9 mths.
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The main factor is dampness due to urine and faeces. Check for faecal impaction/spurious diarrhoea. The commonest type is irritant dermatitis but consider also:
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Claimed to be worse with teething (8–12 mths).
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Keep the area dry.
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Change wet or soiled napkins often—highly absorbable disposable ones are good.
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Wash gently with warm water and pat dry (do not rub).
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Avoid excessive bathing and soap.
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Avoid powders and plastic pants.
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Use emollients to keep skin lubricated (acts as a barrier) e.g. zinc oxide and castor oil cream, or Vaseline, with each change.
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Standard treatment for persistent or widespread rash 1% hydrocortisone with nystatin or clotrimazole cream e.g. Hydrozole (qid after changes)—can get separate steroid and antifungal creams and mix before application. If seborrhoeic dermatitis: 1% hydrocortisone and ketoconazole ointment.