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Treatment of nail disorders

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DOI: 10.1586/14750708.1.1.159

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R EVIEW

Treatment of nail disorders

Bianca Maria Piraccini,
Matilde Iorizzo,
Angela Antonucci and
Antonella Tosti†
†Author
for correspondence
Department of Dermatology,
University of Bologna,
Via Massarenti 1 – 40138
Bologna, Italy
Tel.: +39 051 341 820
Fax: +39 051 347 847
tosti@med.unibo.it
There are several reasons that make the nail unit difficult to treat. It is necessary to wait for
several months before seeing the results of treatments in nail disorders, as the nail plate
grows very slowly (average nail growth is 3 mm/month in fingernails and 1–1.5 mm/month in
toenails). It is very important to give the patients this information, as they may otherwise
discontinue the treatment feeling it to be ineffective. Delivery of topical drugs through the
nail is difficult, as vehicles utilized for enhancing penetration of drugs through the skin are
not effective in the nail. Most topical drugs are therefore ineffective in the treatment of
inflammatory nail disorders, since the nails are largely exposed to environmental hazards and
nail disorders are commonly precipitated or worsened by physical traumas. Thus, clinicians
often do not prescribe systemic treatment when the disease is limited only to the nails.

Brittle nails Topical treatment

Keywords:
drugs, nail diseases, therapy
Future Drugs Ltd
Nail brittleness is a common complaint character-
ized by weak nails that split, flake and crumble. It
may be a consequence of factors that alter the nail
plate production and/or factors that damage the
already keratinized nail plate [1–3]. Since environ-
mental and occupational factors that produce a
progressive dehydration of the nail plate play a
main role in the development of idiopathic nail
brittleness [4], the management of brittle nails
includes protective measures that prevent nail
plate dehydration. Patients should be instructed
to pursue the following rules:
• Avoid repeated immersion of the hands in
soap and water
• Avoid repeated use of nail polish removers that
decrease nail content in water
• Keep nails short and squared, and leave
cuticles uncut
• Protect hands with rubber gloves worn over
light cotton gloves during housekeeping
Cosmetic treatment
Nail hardeners, nail strengtheners and fortify-
ing nail builders are commercially available to
enhance the appearance of nails but there are
no data proving their efficacy. Nail varnishes
may be useful to protect the nail plate from
environmental hazards but they always need to
be removed with nail polish removers. For this
reason, nail polishes should be applied once
a week. In recalcitrant fragility, nail wrapping
limited to the distal portion of the nail plate as
well as preformed artificial nails and sculptured
nails may afford protection and camouflage [5].
Nail moisturizers are useful. They may contain
occlusives such as petrolatum or lanoline and
humectants, such as glycerin and propylenegly-
col. Proteins, fluorides and silicium can also be
useful. Urea and α-hydroxy acids increase the
water binding capacity of the nail plate [5].
Systemic treatment
• Biotin 2.5–5 mg/daily for 6 months [6]
• Iron supplementation is useful ony when ferritin
levels are below 10 ng/ml
• Colloidal silicic acid has been reported effective
at the dosage of 10 ml/day [7]
Onycholysis
Onycholysis describes the detachment of the
nail plate from the nail bed. It may be idio-
pathic, traumatic or may be a symptom of
numerous diseases that affect the nail bed. The
onycholytic area appears whitish due to the
presence of air under the detached nail plate.
It may occasionally present a green or brown
discoloration due to colonization of the ony-
cholytic space by chromogenic bacteria (Pseu-
domonas aeruginosa), molds or yeasts. A water-
borne environment facilitates the development
of this condition.
Topical treatment
• The detached nail plate should be clipped
away and this should be repeated at 2-week
intervals until the nail plate grows attached
• The exposed nail bed should be carefully dried
after each hand washing

2004 © Future Drugs Ltd ISSN 1475-0708 http://www.future-drugs.com Therapy (2004) 1(1), 159–167 159
REVIEW – Piraccini, Iorizzo, Antonucci & Tosti
• Application of a topical antiseptic solution
(4% thymol in chloroform, or in 95% etha-
nol) and/or a topical antifungal on the
exposed nail bed may be useful
• Pseudomonas colonization can be treated with
sodium hypochlorite solution or 2% acetic
acid
• Treatment of the causative condition is
required in all cases of onycholysis secondary
to nail bed diseases
Acute paronychia
Acute paronychia is an acute inflammatory dis-
order affecting the proximal and lateral nail
folds. It is usually caused by Staphylococcus
aureus, although other bacteria and herpes sim-
plex virus (HSV) 1 and 2 may be responsible for
this condition. The affected digit is painful, with
erythema, swelling and pus discharge. Nonpuru-
lent vescicles are typical of HSV infection. Treat-
ment should commence as early as possible to
avoid deeper infections and progression to
chronic paronychia with or without permanent
nail plate damage.
Topical treatment
Drainage of the abscess and local medications
with antiseptics (4% thymol in chloroform or in
95% ethanol) are useful to obtain relief of
inflammation and pain.
Systemic treatment
Whenever possible, cultures should be taken.
Treatment includes penicillase-resistant antibiotics
or systemic acyclovir (Zovirax®, GlaxoSmithKline)
in case of HSV infection.
Chronic paronychia
Chronic paronychia is a chronic inflammatory
reaction of the proximal nail fold due to irri-
tants or allergens. Secondary colonization with
Candida albicans and/or bacteria occurs in
most cases, causing self-limited episodes of
painful acute inflammation.
Clinically, the proximal and lateral nail folds
show mild erythema and swelling. The cuticle is
generally lost. Beau’s lines (transverse superficial
depressions of the nail plate) and onychomadesis
(a transverse whole thickness sulcus that splits
the nail plate into two parts) may occur as a con-
sequence of nail matrix damage. Management of
chronic paronychia requires avoidance of wet
environment, chronic microtrauma and contact
with irritants or allergens.
160
Topical treatment
Application of a mild potency topical steroid at
night and a topical preparation containing a
steroid and an imidazole derivative in the morning.
Systemic treatment
• Systemic steroids (methylprednisone
20 mg/day for a few days) can be prescribed
in severe cases when several digits are affected
• Systemic antifungals are often useless as
chronic paronychia is not a mycotic infection
Candida is a colonizer of the proximal nail fold
that disappears when the proximal nail fold bar-
rier is restored. Eradication of Candida is not
associated with clinical cure [8].
Surgical treatment
Paronychia that is not responding to medical
therapy should be treated by the excision of a cres-
cent-shaped, full thickness piece of the proximal
nail fold, including its swollen portion.
Onychomycosis
Onychomycosis is the most common nail dis-
ease and describes the infection of the nail by
fungi. Approximately 85% of cases of ony-
chomycosis result from dermatophytic invasion
of the nail. Nondermatophytic molds (NDM)
account for 15% of cases, while onychomycosis
due to yeasts are rare.
Onychomycosis affects toenails more frequently
than fingernails. Different clinical patterns of
infection depend on the method by which fungal
colonization of the nail occurs. Distal subungual
onychomycosis (DSO), proximal subungual ony-
chomycosis (PSO), white superficial onychomyco-
sis (WSO), endonyx onychomycosis (EO) and
total dystrophyc onychomycosis (TDO) are the
pattern currently described by the literature.
Treatment of onychomycosis depends on the
responsible fungi, the type of onychomycosis,
the number of affected nails and the patient’s age
and general health. Since differential diagnosis
of onychomycosis includes a large number of
different diseases, treatment should only be
commenced when the diagnosis is confirmed by
a positive microscopy and/or culture [9].
Onychomycosis due to dermatophytes
The affected digit demonstrates subungual hyperk-
eratosis with onycholysis in DSO; proximal leu-
konychia in PSO; superficial friable leukonychia in
WSO. Onychomycosis due to dermatophytes are
most commonly due to Trichophyton rubrum.
Therapy (2004) 1(1)

Topical treatment
• In WSO dermatophyte colonization is limited
to the most superficial layers of the nail plate.
Treatment requires scraping of the affected
area followed by the application of a topical
antifungal nail lacquer for 6–12 months
(amorolfine [Loceryl®, Galderma] 5% nail
lacquer 1–2 times/week or cyclopiroxolamine
8% nail lacquer once a day)
• DSO usually requires systemic antifungals, how-
ever, an exception may be represented by DSO
limited to the distal nail of a few digits. This can
be treated with a nail lacquer as for WSO
Systemic treatment
Terbinafine (Lamisil®, Novartis Pharmaceuti-
cals Corp.) and itraconazole (Sporanox®, Janss-
sen-Cilag) have been demonstrated to reach the
distal nail soon after therapy is commenced and
to persist in the nail plate for a relatively long
time (1 to 6 months) after interruption of
treatment. The persistence of high post-treat-
ment drug levels in the nail permits a short
treatment period with fewer incidences of
relapses and side effects.
• Terbinafine is an allylamine derivative admin-
istered at the dosage of 250 mg per day for
6 weeks (fingernail infections) to 3 months
(toenail infections). Terbinafine can also be
administered as pulse therapy at a dosage of
500 mg daily for 1 week every month for 2 to
4 months [10]. Interactions with other drugs
are extremely rare. Hepatobiliary diseases and
white blood cell disturbances may occur
rarely and patients should be assessed before
commencing treatment.
• Itraconazole is a triazole derivative adminis-
tered as pulse therapy at a dosage of 400 mg
daily for 1 week every month. The duration
of treatment ranges from 2 (fingernail infec-
tions) to 3–4 months (toenail infections).
The drug should be administered with a high-
fat meal to improve its absorption. Due to its
pharmacological interactions, it should be
used cautiously in elderly patients who are
taking multiple drugs.
• Patients treated with systemic antifungals
should be followed up for 4 to 12 months after
discontinuation of therapy to evaluate efficacy.
Cure rates of onychomycosis with systemic
antifungals are of 98% for fingernail infections
and 80% for toenail infections, with terbinafine
being the most effective treatment.
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Treatment of nail disorders – REVIEW
• Recurrences and reinfections are not uncom-
mon (up to 20% of cured patients). Weekly
application of antifungal nail lacquers on the
previously affected nails and antifungal nail
creams on the plantar and interdigital skin
can be performed to attempt to maintain
cures.
• Sequential treatment with itraconazole and ter-
binafine has been utilized to increase cure rates
[11]: the suggested regimen is two pulses of itra-
conazole 400 mg per day for 1 week a month
followed by one or two pulses of terbinafine
500 mg/day for 1 week a month.
Onychomycosis due to NDMS
Although the list of NDM that have been isolated
from nails is relatively long, only a few species are
regularly identified as causing onychomycosis.
These include Scopulariopsis brevicaulis, Fusarium
sp., Acremonium sp., Aspergillus sp., Scytalidium
sp. and Onychocola canadiensis.The presence of
periungual inflammation with or without puru-
lent discharge usually strongly suggests a mold
onychomycosis.
Systemic treatment
Systemic treatment is scarcely useful for ony-
chomycosis due to Acremonium sp., Fusarium sp.,
S. brevicaulis and Scytalidium sp. Itraconazole and
terbinafine are effective in nail infections due to
Aspergillus sp.
Topical treatment
Nail lacquers are quite effective in PSO or DSO
due to S. brevicaulis, Fusarium sp. and Acremo-
nium sp. (Figure 1a & 1b). Chemical nail avulsion
with 40% urea in white petrolatum greatly
increases the chance of cure. Scytalidium sp.
infections are usually unresponsive to treatment.
Candida onychomycosis
Onychomycosis due to C. albicans usually
indicates an underlying immunosuppression
and the condition is almost exclusively seen in
chronic mucocutaneous candidiasis (CMCC),
in HIV-positive patients and patients undergo-
ing long-term steroid treatment. However, iso-
lation of Candida in onychomycosis can be
occasionally observed in immunocompetent
individuals.
Systemic treatment
• Itraconazole 200 mg per day and flucona-
zole (Diflucan®, Pfizer) 150 mg weekly are
161
REVIEW – Piraccini, Iorizzo, Antonucci & Tosti
Figure 1 (A–B). Distal sublungual onychomycosis.
A B
Figure 1 (A–B). Distal subungual onychomycosis due to Fusarium solani improved by 12 months of treatment with ciclopiroxolamine 8%
nail lacquer.
effective. Duration of treatment is 6 weeks
for fingernails and 3 months for toenails
• Recurrences are common if the underlying
predisposing disease persists
Ingrown toenails
Ingrown toenails are a common complaint that
usually affect the big toe of young adults but
they may occur at any age. They may be caused
by an incorrect nail trimming, traumas, podi-
atric abnormalities or hyperhidrosis. The con-
dition is due to a spicule that breaks off from
the lateral edge of the nail plate and penetrates
into the tissues of the lateral nail fold. Con-
servative treatment is indicated for early stages
but advanced disease often requires surgical
treatment for definite cure.
Topical treatment
• Stage I: the embedded spicule must be removed
and a package of nonabsorbent cotton soaked
in a disinfectant (povidone iodine) is placed
under the lateral corner of the nail plate to sep-
arate it from the distal and lateral nail folds.
This medication should be repeated daily.
• Stage II: high potency topical steroid (clobeta-
sol propionate 0.05% ointment [Temovate®,
GlaxoSmithKline]) should be applied for a few
days to promptly reduce the overgrowth of
granulation tissue. Infection is always present
requiring application of topical mupirocin.
Surgical treatment
Stage III: selective destruction of the lateral
horn of the nail matrix is mandatory and may
be achieved by phenol cauterization or by
surgical lateral matrix excision [12].
162
• Phenol cauterization: after removal of the
lateral strip of the offending nail, hemostasis
is achieved with a tourniquet. Then, the sur-
rounding skin is protected with petrolatum
and a saturated solution of phenol 88% is
rubbed to the lateral matrix horn on a small
cotton pack for 3 min, followed by neutrali-
zation with alcohol. The first dressing is per-
formed with an high potency topical steroid
(clobetasol propionate 0.05% ointment) and
changed after 24 h. The patient should be
instructed to soak the foot twice daily in a
quart of warm water containing three cap-
sules of povidone-iodine. This accelerates
healing and prevents possible secondary
infections [12].
• Lateral matrix excision: this may be obtained
by dissecting and excising the lateral matrix
horn [12].
Distal nail embedding
Distal nail embedding is a common complica-
tion of total nail plate avulsion. An overgrowth
of distal soft tissue may occur and the new nail
may penetrate into this, producing inflamma-
tion with pain. Sculptured artificial nails may
be useful to override the distal nail wall.
Surgical treatment
In severe cases, a crescent wedge tissue excision is
performed around the entire distal phalanx.
Congenital malalignment of the
big toenail
Congenital malalignment of the big toenail is
characterized by lateral deviation of the nail
plate with respect to the longitudinal axis of the
Therapy (2004) 1(1)

distal phalanx. Congenital malalignment is pos-
sibly caused by an abnormality in the ligament
that connects the matrix to the periostium of
the distal phalanx. It may be complicated by
nail ingrowing that most commonly involves
the external portion of the lateral nail fold [13].
The condition improves spontaneously in most
cases but may persist into adulthood. If the nail
deviation is mild, the nail may overcome the
initial slight embedding produced by the distal
lip, as it hardens and sufficient normal nail may
grow to the tip of the digit to prevent further
secondary traumatic changes.
Surgical treatment
If the deviation is severe, the congenital mala-
lignment may be corrected surgically before the
age of 2 years.
Onychogryphosis
This condition is typical of the big toenail of
elderly people [14]. Predisposing factors include
trauma, ill-fitting shoes, impaired arterial blood
supply and poor foot care. In onychogryphosis,
the nail plate is thick and uplifted and one side
of the matrix grows faster than the other. The
side which grows faster determines the direction
of the nail plate that is deformed to a ram’s horn
shape. The nail plate is opaque, brown-colored
and with transverse striations. Nail trimming is
extremely difficult.
Topical treatment
Chemical avulsion of the overgrowing nail plate
with 40% urea ointment is useful. The new nail
is then maintained and softened with a daily
application of a cream containing urea and peri-
odical podiatric treatment of nail trimming and
nail unit care.
Pincer nails
Pincer nails are characterized by transverse over-
curvature increasing distally along the longitudi-
nal axis of the nail [15]. The nail plate pinches the
nail bed tissues generating discomfort and pain.
X-ray examination may sometimes reveal an exos-
tosis of the distal phalanx and may be performed
to exclude this occurrence.
Conservative treatment consists of clipping
the lateral edge of the nail plate and positioning
nail braces and elastic bands under the distal
edge. These measures should be performed by
expert podiatrists and do not treat the underly-
ing cause but may improve the overcurvature of
the nail plate.
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Treatment of nail disorders – REVIEW
Surgical treatment
It may vary depending on the severity of the
overcurvature. Generally, phenol cauterization is
performed on the lateral matrix horns.
Psoriasis
Nail changes are reported in up to 50% of psori-
atic patients. The disease usually involves several
nails and both fingernails and toenails may be
affected. Diagnostic signs for nail psoriasis include
irregular pitting, salmon patches of the nail bed
and onycholysis with erythematous border.
Nail psoriasis is often worsened by mechanical
traumas and is poorly responsive to both topical
and systemic treatments. lt is also scarcely influ-
enced by sun exposure and other environmental
factors that improve skin psoriasis. Reassuring
the patient is generally the best treatment option
for mild nail psoriasis.
Topical treatment
• Application of topical calcipotriol 0.005%
(Dovonex®, Leo Pharma) twice a day is useful
for nail bed psoriasis, especially if applied
directly on the nail bed after trimming the
detached nail plate
• Application of topical tazarotene 0.1% gel
(Avage™, Allergan Inc.) with or without
occlusion is another option [16]
• Topical treatment should be prolonged for
several months to see improvements
Intralesional treatment
• Triamcinolone acetonide 5–10 mg/ml, at a
dose of 0.2–0.5 ml per digit should be
injected with an insulin syringe into the
proximal nail fold (in patients with nail plate
surface abnormalities), or in the lateral nail
fold (in patients with subungual hyperkerato-
sis). Injections should be repeated monthly
for 6 months, then every 6 weeks for the next
6 months and finally every 2 months for 6 to
12 months. Cold anesthesia with ethyl chlo-
ride is useful to make the treatment less pain-
ful. Side effects include hemorrhages, pig-
mentary changes and atrophy of the nail fold
skin. Benefits should be apparent in 2–
3 months. Subungual hyperkeratosis and nail
thickening respond better than onycholysis
and pitting.
Systemic treatment
• Acitretin 0.2–0.3 mg/kg/day is a good treatment
for severe nail matrix and nail bed psoriasis
163
REVIEW – Piraccini, Iorizzo, Antonucci & Tosti
• Steroids, methotrexate, cyclosporin A and
some of the new biological agents (infliximab
[Remicade®, Schering-Plough] and etaner-
cept [Embrel®, Wyeth]) are usually very effec-
tive but should only be used when nail psoria-
sis is associated with widespread disease or
psoriatic arthritis
• Onycholysis and pitting can sometimes be
worsened by some of these treatments. Higher
dosages of retinoids may cause side effects on
nails including brittleness and paronychia
with or without pyogenic granuloma
Pustular psoriasis
Pustular psoriasis of the nail is not rare and is often
limited to one or a few digits (Hallopeau’s acroder-
matitis). Diagnosis is suggested by a history of
relapsing painful inflammation of the nail.
The disease is frequently localized in the nail
bed producing onycholysis and periungual ery-
thema. Pustules may be visible through the nail
plate. In severe cases the nail plate is discoloured
and detached by accumulation of pus and scales
that form thick yellow exudating masses.
Involvement of the nail matrix produces acute
paronychia and onychomadesis.
However, in most cases, the patient presents
with subacute signs. The nail plate is onycho-
lytic, shortened and yellow–brown in color and
the exposed nail bed presents mild erythema
and scaling. The clinical history presents, in
these cases, the real clue for diagnosis.
Figure 2 (A–B). Pustular psoriasis treated with acitretin.
A B
A: Pustular psoriasis before treatment; B: After treatment with systemic acitretin.
164
Systemic treatment
Acitretin 0.5 mg/kg/day is effective in prevent-
ing relapses and can produce complete cure in
most cases (Figure 2a & 2b). Duration of treatment
is 4–6 months and recurrences are frequent after
interruption.
Topical treatment
Topical calcipotriol 0.005% twice a day can be
utilized as maintenance treatment to prevent
recurrences [17]. It may be utilized as the sole
treatment when the disease is limited to one
nail or when systemic retinoids are
contraindicated.
Parakeratosis pustulosa
This nail disorder is exclusive to children and
usually involves one digit with psoriasiform nail
changes and may represent a limited form of nail
psoriasis [18].
Topical treatment
• Application of mild steroids and/or retinoic
acid may induce partial remission of the nail
changes
• In most cases, parakeratosis pustulosa resolves
spontaneously
Lichen planus
Nail abnormalities are evident in 10% of
patients with skin or mucosal lichen planus.
However, nail lichen planus most commonly
Therapy (2004) 1(1)

Figure 3 (A–B). Nail lichen planus after intramuscular triamcinolone acetonide.
A B
A: Nail lichen planus before treatment with intramuscular triamcinolone acetonide; B: Nail lichen planus after treatment.
occurs in the absence of skin or mucosal involve-
ment. Nail lichen planus may cause definitive
nail destruction if not properly diagnosed and
treated. Diagnosis of lichen planus of the nails is
suggested by thinning, longitudinal ridging and
fissuring of the nail plate [19]. Pterygium forma-
tion is a possible outcome and indicates nail
matrix scarring.
Systemic treatment
Triamcinolone acetonide 0.5–1 mg/kg intra-
muscularly once a month for 4–6 months.
Almost all patients respond to treatment (Figure
3a & 3b); mild relapses are commonly observed
but recurrences are usually responsive to therapy.
Intralesional treatment
This type of treatment should be performed only
when the disease is limited to a few nails. Triamci-
nolone acetonide should be diluted 5–10 mg/ml
in saline solution and injected to a maximum of
0.2–0.5 ml for each digit. It is advisable to cool
the proximal nail fold before injection to reduce
pain. Injections can be repeated monthly for 3 to
6 months. The most common side effects include
hemorrhages, pigmentary changes and atrophy of
the nail fold skin.
Trachyonychia
Trachyonychia describes an abnormality of the
nail plate surface that is rough due to excessive
longitudinal ridging [20]. The condition com-
monly affects most or all nails and is idiopathic or
associated with alopecia areata. Trachyonychia
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Treatment of nail disorders – REVIEW
associated with alopecia areata occurs in up to
12% of children affected by the disease, especially
those with alopecia totalis or alopecia universalis.
A shiny, less severe, variety of trachyonychia
results from a diffuse regular superficial pitting. In
some patients opaque and shiny trachyonychia
may coexist in different nails. Idiopathic trachy-
onychia may be caused by lichen planus, psoriasis
and alopecia areata limited to the nails.
Treatment
The nail changes tend to regress spontaneously
over the years. For this reason, trachyonychia does
not need to be treated, especially in children.
Yellow nail syndrome
This condition describes a chronic nail disorder
characterized by an arrest or reduction in nail
growth resulting in nail thickening, hardening
and yellow discoloration. In the classic presen-
tation it is associated with lymphoedema and
respiratory tract disturbances. It may be a para-
neoplastic condition. The nail changes may
improve spontaneously or after resolution of
the associated systemic disease.
Systemic treatment
• Oral vitamin E at dosages of 600 to 1200 IU
daily for 6–18 months may induce a complete
clearing of the nail changes. Although the mech-
anism of action of vitamin E in yellow nail syn-
drome is still unknown, anti-oxidant properties
of α-tocopherol may account for its efficacy
165
REVIEW – Piraccini, Iorizzo, Antonucci & Tosti

• Pulse therapy with itraconazole 400 mg daily
for one week in a month for 4 to 6 month.
Although the mode of action of itraconazole
in treating yellow nail syndrome is still
unknown, the drug may act by accelerating
nail growth. However, in the experience of
this group, it is scarcely effective [21]
Warts
Warts are infections caused by human papillo-
mavirus and originate in the hyponychium and
proximal and lateral nail folds that possess a
granular layer. They appear as hyperkeratotic
papules or as a diffuse hyperkeratosis of the cuti-
cle. Periungual and subungual warts are usually
difficult to treat and frequently recur [22].
Topical treatment
• Topical antiwart solutions containing salicylic
and lactic acids are of moderate efficacy, as well
as topical imiquimod 5% cream
• Topical immunotherapy with strong sensitiz-
ers (squaric acid dibuthylester [SADBE] or
diphencyprone) is an effective and painless
modality of treatment for multiple warts.
SADBE or diphencyprone 2% in acetone are
used for sensitization. After 21 days, weekly
applications are carried out with dilutions
selected according to the patient’s response.
Complete cure usually requires 3 to 4 months
Intralesional treatment
Bleomycin has been successfully used to treat
viral warts for many years. The powder should
be diluted to a concentration of 1IU per ml
Highlights
• Nails are difficult to treat, as it is necessary to wait for several months
before seeing the results of treatments and delivery of topical drugs is
difficult through the nail.
• Several nail disorders are now easily treated, or at least improved, by
clinical practices.
with saline solution. After local anesthesia,
which may be achieved by a digital block, the
bleomycin solution is dropped onto the wart,
which is then punctured with a disposable
bifurcated needle approximately 40 times per
5 mm2 area of the wart.
No medications are required. Three weeks
after treatment the eschar can be pared away and
the area examined for residual warts, which can
be retreated if necessary.
Surgical treatment
Subungual warts first require removal of the
nail plate covering the wart under local anesthe-
sia. Curettage is then performed. This is fol-
lowed by application of an antibiotic ointment
and thick gauze padding. A carbon dioxide
lazer can successfully be used to treat subungual
and periungual warts.
Expert opinion
Nails are difficult to treat and often require
long-term treatment. Numerous factors are
well known to influence the speed of nail
growth, but unfortunately many of these are
unmodifiable, such as age and gender. Some
medications can be administered to cure the
nails but also to alter the rate of nail growth,
thus providing a more rapid and complete
response to treatment. Nail disorders should
always be treated because of the important role
of the nails in everyday life.
Outlook
In the last few years new treatments and for-
mulations have become available to treat nail
disorders, helping clinicians improve patient
care. However, we believe more could be done,
especially for vehicles that are often not effec-
tive in the nail. In this way, nail disorders
could be treated from outside rather than
inside with systemic treatments that have
much more interaction with other drugs taken
by the patient.

Bibliography
Papers of special note have been highlighted as
either of interest (•) or of considerable interest (••)
to readers.
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2 Helmdach M, Thielitz A, Ropke EM,
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3 Brosche T, Dressler S, Platt D. Age-
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human scalp hair and finger nail clippings.
Aging (Milano) 13(2), 131–138 (2001).
•• Suggests the important role of lipids in
the development of nail brittleness in
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4 Lubach D, Beckers P. Wet working
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5 Abimelec P. Cosmetology and brittle
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166 Therapy (2004) 1(1)


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7 Lassus A. Colliodal silicic acid for oral and
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and brittle nails in females. J. Int. Med.
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8 Tosti A, Piraccini BM, Ghetti E,
Colombo MD. Topical steroids versus
systemic antifungals in the treatment of
chronic paronychia: an open, randomized
double-blind and double dummy study. J.
Am. Acad. Dermatol. 47(1), 73–76
(2002).
• Demonstrates the effective role of
Candida in chronic paronychia.
9 Tosti A, Piraccini BM, Lorenzi S, Iorizzo
M. Treatment of nondermatophyte mold
and Candida onychomycosis. Dermatol.
Clin. 21(3), 491–497 (2003).
•• A review of NDM and Candida
onychomycosis both in its clinical
presentations and treatments.
10 Tosti A, Piraccini BM, Stinchi C et al.
Treatment of dermatophyte nail
infections: an open randomized study
comparing intermittent terbinafine
therapy with continuous terbinafine
treatment and intermittent itraconazole
therapy. J. Am. Acad. Dermatol. 34(4),
595–600 (1996).
11 Gupta AK, Lynde CW, Konnikov N.
Single-blind, randomized, prospective
study of sequential itraconazole and
terbinafine pulse compared with
terbinafine pulse for the treatment of
toenail onychomycosis. J. Am. Acad.
Dermatol. 44(3), 485–491 (2001).
www.future-drugs.com
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Treatment of nail disorders – REVIEW
12 Haneke E. Nail surgery. Eur. J. Dermatol.
10(3), 237–241 (2000).
•• Etiology and treatment of nail
malalignment are well detailed by the
authors.
13 Baran R, Haneke E. Etiology and
treatment of nail malalignment. Dermatol.
Surg. 24(7), 719–721 (1998).
14 Cohen PR, Sher RK. Geriatric nail
disorders: diagnosis and treatment. J. Am.
Acad. Dermatol. 26(4), 521–531 (1992).
15 Baran R, Haneke E, Richert B. Pincer
nails. Definition and surgical treatment.
Dermatol. Surg. 27(3), 261–266 (2001).
16 Scher RK, Stiller M, Zhu YI. Tazarotene
0.1% gel in the treatment of fingernail
psoriasis: a double-blind, randomized,
vehicle-controlled study. Cutis 68(5),
355–358 (2001).
17 Piraccini BM, Tosti A, Iorizzo M, Misciali
C. Pustular psoriasis of the nails:
treatment and long-term follow-up of 46
patients. Br. J. Dermatol. 144(5), 1000–
1005 (2001).
18 Tosti A, Peluso AM, Zucchelli V. Clinical
features and long-term follow-up of 20
cases of parakeratosis pustulosa. Pediatr.
Dermatol. 15(4), 259–263 (1998).
19 Tosti A, Peluso AM, Fanti PA, Piraccini
BM. Nail lichen planus: clinical and
pathologic study of 24 patients. J. Am.
Acad. Dermatol. 28(5), 724–730 (1993).
20 Tosti A, Piraccini BM, Iorizzo M.
Trachyonychia and related disorders:
evaluation and treatment plans. Dermatol.
Ther. 15, 121–125 (2002).
• Author's experience with the use of
itraconazole in the YNS.
21 Tosti A, Piraccini BM, Iorizzo M.
Systemic itraconazole in the yellow nail
syndrome. Br. J. Dermatol. 146(6), 1064–
1067 (2002).
•• Review of warts of the nail unit and its
treatment.
22 Tosti A, Piraccini BM. Warts of the nail
unit: surgical and nonsurgical approaches.
Dermatol. Surg. 27(3), 235–239 (2001).
23 Geyer AS, Onumah N, Uyttendaele H,
Scher RK. Modulation of linear nail
growth to treat diseases of the nail. J. Am.
Acad. Dermatol. 50(2), 229–234 (2004).
Affiliations
• Bianca Maria Piraccini, MD, PhD
Department of Dermatology, University
of Bologna Via Massarenti 1–40138
Bologna (Italy)
Tel.: +39 051 341 820
Fax: +39 051 347 847
• Matilde Iorizzo, MD
Department of Dermatology, University
of Bologna Via Massarenti 1–40138
Bologna (Italy)
Tel.: +39 051 341 820
Fax: +39 051 347 847
• Angela Antonucci, MD
Department of Dermatology, University
of Bologna Via Massarenti 1–40138
Bologna (Italy)
Tel.: +39 051 341 820
Fax: +39 051 347 847
• Antonella Tosti, MD
Department of Dermatology, University
of Bologna Via Massarenti 1–40138
Bologna (Italy)
Tel.: +39 051 341 820
Fax: +39 051 347 847
tosti@med.unibo.it
167