Print this page Email this page
Users Online: 783
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 158-161

Nail avulsion with adjuvant therapy in nail disorders


Department of Skin and Venereal Diseases, Smt. Shardaben Chimanlal Lalbhai Municipal General Hospital, Saraspur, Ahmedabad, Nathiba Hargovandas Lakhmichand Municipal Medical College, Gujarat, India

Date of Web Publication8-Dec-2014

Correspondence Address:
Dr. Hiren P Suthar
D 101, Shree Darshan Apartment, In front of Simandhar Residency 2, Shayona City Road, Chandlodia, Ahmedabad - 382 481, Gujarat
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.146421

Rights and Permissions
  Abstract 

Background: Nail avulsion is a commonly performed office procedure. It can be used successfully along with other adjuvant therapies in various nail disorders. The objective of this study was to evaluate the efficacy and safety of nail avulsion in nail disorders.
Patients and Methods: A total of 35 patients with nail changes of onychomycosis, ingrown toenail, subungual or periungual wart and dystrophic nail were studied over a period of 2 years. Nail avulsion was carried out in each patient with adjuvant therapy in the form of electrosurgery, chemical matricectomy and systemic antifungal medications. Each patient was reviewed for any postoperative complication and recurrence.
Results: Most common nail disorder was onychomycosis (60%). Male: Female ratio was 1: 1.3. Maximum recurrence rate was seen in subungual or periungual wart (20%). No postoperative long-term complications were seen.
Conclusion: Nail avulsion is a simple, easy-to-carry procedure. Recurrence of certain nail disorders can be decreased by combining nail avulsion with other adjuvant therapy.

Keywords: Chemical matricectomy, electrosurgery, nail avulsion, onychomycosis


How to cite this article:
Suthar HP, Patel NM, Solanki AD, Barot JP. Nail avulsion with adjuvant therapy in nail disorders. Arch Int Surg 2014;4:158-61

How to cite this URL:
Suthar HP, Patel NM, Solanki AD, Barot JP. Nail avulsion with adjuvant therapy in nail disorders. Arch Int Surg [serial online] 2014 [cited 2024 Mar 28];4:158-61. Available from: https://www.archintsurg.org/text.asp?2014/4/3/158/146421


  Introduction Top


The nail is a subject of global importance for dermatologists. Nail avulsion is a frequently undertaken, yet simple, intriguing procedure. It is the excision of the body of the nail plate from its primary attachments, the nail bed ventrally and the proximal nail fold (PNF) dorsally. It may either be useful to explore the nail unit for diagnostic purposes or as a therapeutic tool in particular nail pathologies. Four most common indications of nail avulsion are recalcitrant ingrown toenail, chronic onychomycosis, subungual and periungual wart, and dystrophic nails.

Other less common indications are [1] exploration of the nail bed and the nail matrix to look for the pathologies, exploration of the PNF and lateral nail fold, performing biopsy on the nail bed and the nail matrix, melanonychia, onychogryphosis (a deformed and curved nail), chronic recurrent paronychia, retronychia: Reverse embedding of the nail plate into the PNF, pincer nails ("Omega nails" and "Trumpet nails") and onychomatricoma. Nail avulsion may be accomplished using either a distal or a proximal anatomical approach. Distal nail avulsion is the most frequently used technique, in which the nail plate is released from its attachment from the nail bed at the hyponychium. [2] In proximal nail avulsion, the nail plate is separated from the PNF followed by a complete separation moving distally. [2] It is attempted when creating a cleavage plane between the nail plate and the nail bed distally is impossible because of the presence of distal nail dystrophy, which prevents access to the distal-free edge of the nail plate. This presentation may be seen in distal subungual onychomycosis. [3],[4],[5] A third method, chemical avulsion with urea paste, is a nonsurgical avulsion technique that may be performed. A partial or complete nail avulsion can be performed, depending on the location and extent of disease. Adjuvant therapy: In nail disorders like ingrown toenail, onychomycosis, subungual and periungual warts adjuvant therapies are used to increase efficacy of procedures and to prevent recurrence. Chemical matricectomy: Multiple indications for performing matricectomy exist, the most common being the diagnosis of recalcitrant recurrent ingrown nails. [2],[6],[7],[8] Chemical cauterization of the nail matrix with the application of phenol is used to temporarily or permanently destroy the matrix. Electrosurgery: The application of low-voltage current by means of electrodesiccation and enucleation to dehydrate and detach the wart from the dermis has proven efficacious in the treatment of common warts of the nail. Electrosurgery is associated with an excellent cure rate. However, scarring may be significant. Systemic Antifungals: In case of onychomycosis, after the nail avulsion systemic antifungal medications are given to patients to prevent development of recurrence. The objective of this study was to study the role of adjuvant therapy with nail avulsion in nail disorders.


  Patients and Methods Top


This study was done in the department of dermatology of a tertiary care center in Ahmedabad. A total of 35 patients presenting with nail changes of onychomycosis, ingrown toenail, subungual or periungual wart and dystrophic nail were included in the study over a duration of 2 years. Nail avulsion was a simple OPD-based procedure and did not require admission of the patient. Informed consent and photographs were taken from all the patients before starting the study. Routine investigations, including complete hemogram and fasting blood sugar were done in all the patients. Patients with vascular disease were excluded. If infection was present before the operation, it was treated initially by topical and oral antibiotics. Surgical treatment was instituted as soon as the nail and skin fold became dry. Anesthesia of the digit was achieved through a digital block performed with plain 1% lidocaine. In distal nail avulsion, the nail spatula was introduced under the distal-free edge of the nail plate to separate the nail plate from the underlying nail bed hyponychium on its ventral surface. All attempts at separation were directed proximally toward the matrix, with significant resistance occurring until the matrix was reached. After reaching the matrix, the elevator was reinserted with several longitudinal forward and backward strokes performed side by side until the nail bed was completely freed from the overlying nail plate. To free the nail plate from its association with the PNF and the cuticle, the free elevator was inserted under the PNF in the proximal nail groove between the eponychium and the nail plate. Next, the clamp was used to gently secure and remove the nail plate. Hemostasis was achieved with direct thumb pressure. The wound was dressed with 2% mupirocin ointment, followed by longitudinal and circumferential gauze wrapping. The dressing was then secured with adhesive tape. After the operation, oral paracetamol (500 mg) thrice daily was given for 5 days for pain control. Pain measurement was done based on visual analog scale (VAS). [9] The dressing was removed after 24 hours in the clinic and then each patient was reviewed weekly until full wound healing was achieved. The patients were followed for 18 months to see for any recurrences and complications.

Chemical matricectomy: In ingrown toenail after nail avulsion, curette was used for curettage of the hyponychium, the lateral nail groove, the lateral matrix horn and the proximal matrix. An exsanguinating tourniquet was used to maintain a bloodless surgical field. A supersaturated solution of 88% phenol was used. A sterile cotton-tipped applicator dipped in the concentrated phenol solution was directed laterally into the recessed area of the lateral matrix horn and dorsally to contact the matrix tissue on the ventral surface of the PNF. During the procedure, the cotton applicator was used to vigorously massage the matrix with a twisting motion [Figure 1]a and b. Bleeding was usually minimal and was controlled with direct pressure. Dressing and follow-up of patients was done as described above.
Figure 1: (a) Ingrown toenail (pre-op) (b) Ingrown toenail (post-op)

Click here to view


Electrosurgery: It was done in two steps to soften, destroy, demarcate and separate the wart from its attachment to the dermis. In the first step (electrodesiccation), a needle was directly applied to the surface of small warts or intralesionally applied to larger, thicker warts under low-voltage current. Bleeding was controlled with electrocautery or by digitally compressing the lateral digital arteries. In the second step, the charred tissue was removed with a curette, carefully avoiding the dermis and the nail matrix to prevent scarring (enucleation) [Figure 2]a and b. Periungual warts were also treated similarly.

Systemic antifungals: After nail avulsion, patients with onychomycosis were put on tablet terbinafine 250 mg daily for one and half months for fingernails and for two and half months for toenails [Figure 3].
Figure 2: (a) Periungual wart (pre-op) (b) Periungual wart (post-op)

Click here to view
Figure 3: (a) Onychomycosis (pre-op) (b) Onychomycosis (post-op)

Click here to view



  Results Top


In our study, the most common age group was 21-30-years affecting 40% of total patients [Table 1]. The male:female ratio was 1:1.3. Most common nail disorder was onychomycosis (60%) [Table 2]. After nail avulsion, recurrence rate was the maximum in patients of subungual/periungual wart (20%) [Table 3]. Partial nail avulsion was carried out in two patients of periungual wart while total nail avulsion was done in remaining 33 patients. Out of 35 patients, 23 had mild pain (5-44 mm on VAS), 8 had moderate pain (45-74 mm on VAS) and 4 had severe pain (75-100 mm on VAS) for 3 days after nail avulsion. The postoperative healing period ranged from 2 to 4 weeks.
Table 1: Age and Sex distribution

Click here to view
Table 2: Number of patients in each group

Click here to view
Table 3: Recurrence rate in each disorder

Click here to view



  Discussion Top


Nail avulsion is an easy-to-carry office procedure with minimal complications and excellent outcome. There are various stages of ingrown toenail. In stage 1, there is erythema, slight edema and pain, particularly with pressure. In stage 2, there is an increase in the severity of symptoms, the wound becomes locally infected and starts to drain. In stage 3, all signs and symptoms are amplified and there is associated formation of granulation tissue and lateral wall hypertrophy. There are many options for the treatment of ingrown toenail, ranging from simple conservative approaches to relatively extensive surgical procedures requiring considerable surgical experience. [7],[10],[11] A chemo-surgical technique for permanent matricectomy is ideal for the ingrown toenail. Phenol matricectomy is the most widely practiced matricectomy procedure. [6],[12],[13] Phenol (C 6 H 5 OH) is a colorless crystal derived from coal tar. Liquefied phenol (carbolic acid) has antibacterial, anesthetic and in its concentrated form, escharotic properties. It denatures protein and retains antibacterial and anesthetic properties. [14] It has a success rate of 95% and higher, [6],[12],[13] and postoperative morbidity is minimal. A supersaturated solution of 88% phenol is usually useful. A total of three 30-second applications of phenol are required in partial matricectomy and five 30-second applications in complete matricectomy. [2],[12] Bloodless field is required for 2 reasons:

  1. Blood is known to inactivate phenol. [6]
  2. A dry surgical field helps to facilitate contact between the matrix and the chemocauterant.


It appears to lower the rate of recurring nail spicules in the lateral nail horn area, resulting in higher cure rates and a better treatment outcome. [6]

The application of low-voltage current by means of electrodessication and enucleation to dehydrate and detach the wart from the dermis has proven efficacy in the treatment of common warts of the nail unit. The current essentially cooks and vaporizes the contents of the wart. During surgery, bleeding may be profuse when neovascular dermal capillary loops are interrupted; bleeding is often controlled with electrocautery, Monsel solution or Gelfoam pads. Moderate bleeding can be controlled with electrocautery or by digitally compressing the lateral digital arteries. Electrosurgery is associated with an excellent cure rate. However, scarring may be significant. Healing occurs by secondary intention in 3-4 weeks. Potential complications of this procedure include thermal injury to surrounding soft tissues and the adjacent bony phalanx. [1] Peripheral vascular disease, collagen vascular disease, diabetes mellitus, disorders of hemostasis, acute infection or inflammation of the nail unit, including the surrounding paronychial tissues are relative contraindications to performing surgery in the nail unit. [15] Meticulous postoperative care is essential for a successful nail avulsion. Complications are seldom encountered in nail avulsion. These largely result from nail matrix damage and present with postoperative nail deformity. Pain is the most common complication following nail avulsion. It is usually of short duration and responds well to analgesics. [16] In our study, no postoperative long-term paresthesia, secondary infection, bleeding during procedure were seen. The patient should be advised to keep the operated limb elevated so as to minimize the pain and swelling. Besides, minimal activity with the involved limb, especially if toenails are avulsed, should be carried out for at least 2 weeks.


  Conclusion Top


Nail avulsion is a subject that has not been given attention by dermatologists. One needs to be well-versed with the anatomy of the nail while undertaking a nail avulsion to avoid matrix and nail fold injury. Total nail avulsion has been the conventional method to deal with various nail unit pathologies; however, partial avulsion has gained popularity due to its simplicity and fewer postoperative complications. Ingrown toenail, chronic onychomycosis and periungual warts continue to be the most common indications for nail avulsion. Careful patient selection and maintenance of asepsis during and after the procedure and gentle handling of matrix and nail folds are key to superior outcomes of the procedure.

 
  References Top

1.
Clark RE, Madani S, Bettencourt MS. Nail surgery. Dermatol Clin 1998;16:145-64.  Back to cited text no. 1
    
2.
Siegle RJ, Swanson NA. Nail surgery: A review. J Dermatol Surg Oncol 1982;8:659-66.  Back to cited text no. 2
[PUBMED]    
3.
Dawber RP, Baran R. Diseases of the Nail. Oxford: Blackwell Science; 1994.  Back to cited text no. 3
    
4.
Scher RK. Surgical avulsion of nail plates by a proximal to distal technique. J Dermatol Surg Oncol 1981;7:296-7.  Back to cited text no. 4
[PUBMED]    
5.
Baran R. Surgery of the nail. Dermatol Clin 1984;2:271.  Back to cited text no. 5
    
6.
Ceilley RI, Collison DW. Matricectomy. J Dermatol Surg Oncol 1992;18:728-34.   Back to cited text no. 6
    
7.
Siegle RJ, Stewart R. Recalcitrant ingrowing nails. Surgical approaches. J Dermatol Surg Oncol 1992;18:744-52.  Back to cited text no. 7
    
8.
Kayalar M, Bal E, Toros T, Ozaksar K, Gürbüz Y, Ademoglu Y. Results of partial matrixectomy for chronic ingrown toe nail. Foot Ankle Int 2011;32:888-95.  Back to cited text no. 8
    
9.
McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: A critical review. Psychol Med 1988;18:1007-19.  Back to cited text no. 9
    
10.
Issa MM, Tanner WA. Approach to ingrowing toenails: The wedge resection/segmental phenolisation combination treatment. Br J Surg 1988;75:181-3.  Back to cited text no. 10
    
11.
van der Ham AC, Hackeng CA, Yo TI. The treatment of ingrowing toenails. A randomised comparison of wedge excision and phenol cauterisation. J Bone Joint Surg Br 1990;72:507-9.  Back to cited text no. 11
    
12.
Salasche SJ. Surgery. In: Scher RK, Daniel CR, editors. Nails: Therapy, Diagnosis, Surgery. Philadelphia: WB Saunders; 2005. p. 326-49.  Back to cited text no. 12
    
13.
Leshin B, Whitaker DC. Carbon dioxide laser matricectomy. J Dermatol Surg Oncol 1988;14:608-11.  Back to cited text no. 13
    
14.
Rinaldi R, Sabia M, Gross J. The treatment and prevention of infection in phenol alcohol matricectomies. J Am Podiatry Assoc 1982;72:453-7.  Back to cited text no. 14
[PUBMED]    
15.
Scher RK. The nail. In: Roenigk RK, Roenigk HH, Ratz JL, editors. Dermatologic Surgery-Principles and Practice. 2 nd ed. New York: Marcel Dekker; 2006. p. 281-8.  Back to cited text no. 15
    
16.
Lai WY, Tang WY, Loo SK, Chan Y. Clinical characteristics and treatment outcomes of patients undergoing nail avulsion surgery for dystrophic nails. Hong Kong Med J 2011;17:127-31.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 Treatment and management strategies of onychomycosis
R. Aggarwal,M. Targhotra,B. Kumar,P.K. Sahoo,M.K. Chauhan
Journal de Mycologie Médicale. 2020; : 100949
[Pubmed] | [DOI]
2 Novel Drug Delivery Strategies for the Treatment of Onychomycosis
Rupinder K. Dhamoon,Harvinder Popli,Madhu Gupta
Pharmaceutical Nanotechnology. 2019; 7(1): 24
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed6666    
    Printed227    
    Emailed0    
    PDF Downloaded350    
    Comments [Add]    
    Cited by others 2    

Recommend this journal