Nails: Everything You Need to Know

Podiatrist Tracey Vlahovic, DPM, FFPM, RCPS, (Glasg), delivered an illuminating lecture on nails before a packed room of DermPAs™ and others the SDPA summer conference in Boston in June. She began her discussion reviewing nail anatomy and the proper way to examine nails. For example, nails should be void of all polish, gel and acrylics and examined in good light. When evaluating the toenails, she recommends having the patients bend their knees with their feet flat on their floor to help with dermatoscopic evaluation. It is important to determine if a patient’s anatomy could be contributing to mechanical disturbance of the nail. For example, she sees toenail dystrophy commonly caused by steel toe boots. Dystrophy and hypertrophy of the 5th toenail may be due to the way in which a patient’s toe is rotated causing repetitive trauma to the nail.

Coverage: SDPA Annual Summer Dermatology Conference, June 22-25, 2023 – BOSTON

Dr. Vlahovic reports that when evaluating abnormal nails, she finds onychomycosis (OM) is the diagnosis 50% of the time. Both FDA approved and off-label treatment options for mild to severe OM were highlighted. Dr. Vlahovic stresses the importance of tempering expectations of patients with severe OM who may not be able to achieve complete resolution of their nail dystrophy. She recommends the use of UV shoe sanitizers for prevention of repeated exposure to dermatophytes. On the other hand, she does not recommend total nail avulsion for OM. Nail avulsion is not curative for nail fungus and often results in cosmetic sequelae including a disappearing nail bed. Additional treatments she has found to be unsuccessful for OM include duct tape, Vicks® VapoRub®, tea tree oil, tolnaftate and undecylenic acid. While terbinafine resistance is being increasingly reported, Dr. Vlahovic does not routinely run terbinafine resistance panels. When a patient presents with treatment-resistant disease, expanding the differential is always warranted including the consideration of lichen planus and psoriasis. How to properly collect a nail specimen was reviewed with Dr. Vlahovic recommending debridement of the distal nail and curetting from the proximal nail bed.

Lastly, the differential diagnosis for longitudinal melanonychia was outlined with a nail algorithm for pigmentation. Causes of longitudinal melanonychia include medications, endocrine disorders, nutritional disorders, inflammatory conditions, and exogenous causes of discoloration. It is imperative to have a high index of suspicion for melanoma in any patient who has destruction of their nail bed or a nail bed that is unable to heal. When biopsying the nail, Dr. Vlahovic recommends using a punch biopsy of the origin of the pigment, typically the distal nail matrix. A tip she imparted was soaking the nail first to help soften the nail leading to more ease with the biopsy.

Byline: Sarah B.W. Patton

Pictured: Tracey Vlahovic, DPM, FFPM, RCPS (Glasg)

Editor’s Note:  Tracey Vlahovic, DPM, FFPM, RCPS (Glasg) is featured in a webinar titled, “Nail Disease,” located on SDPA’s website accessible here: Earn 1 AAPA Category 1 CME credit by watching the webinar. Free for SDPA members.