In this month’s column, Dr. Stern discusses her patients’ top nail-related cosmetic concerns, such as ridging and thickened toenails.
Many of the nail conditions I treat involve issues that overlap both the cosmetic and health-related aspects of nails. For example, a medical issue may appear in the nail as unsightly or unattractive to a client who then engages with a nail technician requesting to cover or mask the issue. Or a patient may think that a nail issue is purely cosmetic when in reality it is indicative of a systemic health issue. Nail issues can also arise due to adverse reactions to cosmetic products or procedures. There is, therefore, tremendous overlap between the beauty and health aspects of nails. It is for this reason that I believe it is imperative for physicians and nail technicians to collaborate in order to achieve the best outcomes for our clients and patients.
Here are some of the more common cosmetic nail concerns I see in my practice.
Polish staining is more common with darker polish shades because there is more pigment that can potentially migrate and leach into the surface of the nail.
Polish staining can result in a yellow to orange, sallow, discolored nail. There are several causes for yellow nails and when I see a patient with this presentation, I need to take a thorough history — both medical and nail cosmetic-related. I combine this with my observations from the physical exam, and piece together a diagnosis. Once I have ruled out medical causes such as fungus or circulatory compromise, for example, we can address the cause of the yellow nails. Polish staining occurs because the porosity of the nail is variable. Certain people with more porous nails are more prone to pigment migration and thus yellowing. Additionally, polish remover dissolves polish and this can make the pigments migrate and leach. It is possible that we may observe more yellowing with the gel-polish manicures that require 10-minute soaks in acetone for removal. The third variable is dye content. Not all polish dyes are alike. The darker the color, the more pigment there is that can potentially migrate and leach and this issue is therefore more common with darker polish shades. Polish staining is an issue with all brands, and is more shade dependent than brand dependent. Staining can also happen with light colors, however. Treatment includes reassurance to my patients that the pigment will fade in approximately two weeks. It is also important to ask about base coat usage. A good base coat will provide an important layer of protection to the nail and sometimes the at-home manicurist is not aware of the rationale behind using a base coat.
Some patients mistakenly believe their thickened toenails are the result of a fungal infection.
Thickened toenails can be a common nail complaint and often patients erroneously assume that they have a fungal infection. In reality what many don’t realize is that our foot biomechanics dictate our nail thickness to a large degree. The nail begins growing about half way between the distal joint and the cuticle. Any friction or trauma overlying this region of the digit will therefore put pressure on the delicate matrix (where the nail grows from) resulting in the formation of a thicker nail. The cause is therefore a mechanical one. My patients often wonder why their nails look different now from when they were younger. It is important to understand that as our feet change so do our nails. In cases where a patient has foot pain or pressure-induced foot changes, I will refer them to a podiatrist for evaluation for orthotics. Theoretically if the pressure can be relieved, the nail will have an opportunity to grow in more normally.
The white patches seen on several of the toenails are keratin granulations.
Keratin granulations can occur when the superficial layers of nail cells are inadvertently removed along with polish, leaving a nail with uneven, white, rough patches. These surface abnormalities often appear on several nails and will grow out and fade with time. Keratin granulations can be treated by moisturizing the nail. To expedite resolution of the problem, one can gently buff the nail with a super-fine-grit buffer in order to remove any surface abnormalities. A nail polish holiday for several weeks will also help treat keratin granulations.
Ridging can be associated with aging or medical conditions such as underactive thyroid and Raynaud’s disease.
Ridging is often thought of as a cosmetic issue, however longitudinal ridges in the nail known as onychorrhexis can at times be secondary to a medical condition such as underactive thyroid, Raynaud’s disease, or aging. As we age, nail physiology can change and parts of the nail growth plate (nail matrix) can become thinner or atrophy resulting in ridges. Aging also leads to compromised peripheral circulation (less blood flow to the extremities) and can result in ridging. When the condition is severe, ridged nails can split or break. Nail ridging is rarely secondary to internal medical conditions.
So when should we be concerned? If a patient tells me she has always had great nails and suddenly they are ridged and breaking excessively, I would go into a more detailed medical history, check blood work including thyroid studies, and look at dietary changes (i.e., lack of protein). Treatment of nail ridging without an obvious cause can be challenging. I advise my patients to always wear gloves for household and wet work chores, especially when washing dishes. I also advise them to avoid excessive use of hand sanitizers containing alcohol. Alcohol is extremely drying to nails and skin. Instead, I suggest using a moisturizing cleanser or body wash in a travel dispenser. Nail cosmetics, especially nail polish remover, can dehydrate the nail and cause the nail to be ridged and brittle. In some cases a layer of nail polish actually helps the integrity of the nail plate by reinforcing it with a protective coating. I recommend to patients who use nail polish not to remove it more than once a week. Non-acetone nail polish removers can be less drying. I also recommend a two- to four-week nail polish holiday if the nails are peeling, chipping, and breaking easily.
Dr. Dana Stern
Dermatologists treat skin, hair, and nails. I am a board-certified dermatologist and I specialize in the treatment of nail disorders including nail infections, inflammatory diseases of the nail, cosmetic issues related to the nail, cancers of the nail, and sports-related nail injuries. I also perform surgery on the nail, including biopsies and excisions. Most of my consults are from other dermatologists, physicians, or patients who have read about me. I also see patients referred from nail salons.
You can contact Dr. Stern with your questions via Facebook (www.facebook.com/danasternmd) or Twitter (@DrDanaStern). Visit her website at www.drdanastern.com.
Read previous “day in the life” articles by Dr. Stern at www.nailsmag.com/danastern.