Pterygium is a medical condition in which the skin grabs onto the nail plate and grows forward as the nail grows out, making the nail look as if the cuticle is growing over it. In even more unusual cases, the skin of the fingertips is attached to the underside of the nail. The nail itself may be thin, fragile, pitted, or ridged—or there may be no symptoms at all.
Only a small percentage of people have this condition, which may make their cuticles sensitive and their fingertips uncomfortable. And the condition has many causes and serious consequences.
The word pterygium comes from the Greek root pter, which means wing—referring to the wing-like shape the skin takes on as the nail grows out.
“Years ago, it was commonly thought that pterygium was excess cuticle that needed to be pushed back,” says Renee Meyers, a nail technician and educator for OPI based in Hazelton, Pa. “We now know that pterygium is a serious condition that can actually split the nail plate in half”
Nail technicians can easily mistake overgrown cuticles for pterygium, says Dr. Nia Terezakis, a New Orleans dermatologist who treats nail diseases. If a technician thinks she sees the condition, Terezakis cautions, chances are it’s actually a case of badly overgrown cuticles—what she calls “pseudo-pterygium.”
“It’s not something most manicurists are going to see, even in a lifetime,” says Terezakis, who also is a clinical professor of dermatology at Tulane and Louisiana State universities. “I’ve only seen it a couple of times a year, and I’m a busy dermatologist”
Pterygium must be treated by a doctor, though treatment may not always be effective. But like so many other medical conditions, pterygium also challenges alert technicians to be an advance warning system for their clients by recognizing serious systemic problems in their early stages.
How Pterygium Happens
Pterygium occurs when the nail matrix that creates the nail is somehow damaged.
“The matrix is like a big, flat, wide hair follicle,” says Dr. John C. Powers, a dermatologist and assistant clinical professor at the University of California, San Diego, Department of Dermatology. When something happens to damage the matrix, scar tissue forms. The scar tissue doesn’t work the same way as the tissue it is replacing, so the scar doesn’t produce a normal nail. In serious cases, the nail may grow out, split in half, or only grow to one side.
And the long, tough scar cells are sticky — remember that their fob is to hold together the remaining tissue. So if the nail does grow out, the scar tissue at the matrix or in that area grabs on to the nail plate. Instead of folding under at the nail base, it stretches the skin over the nail as the nail grows out, Powers says.
This scarring most often occurs when the matrix is physically damaged, typically by a trauma such as getting the finger smashed in a door or hit by a hammer. It may occur after surgery that cuts into the matrix, such as that to remove persistent ingrown toenails.
A less common cause is lichen planus, a little-understood disease akin to psoriasis, but more destructive, Terezakis says. The body attacks the place where the outer layer of skin (dermis) and the inner layer (epidermis) come together. If lichen planus takes hold in the eponychium—the area of skin above the matrix — the resulting inflammation can spread to the matrix and scar it.
Other causes include scleroderma, a connective-tissue disease that affects collagen; it can reduce circulation at the fingertips and cause ulcers. Another is Raynaud’s Syndrome, which impairs circulation in the hands and causes them to be cold and bluish; it can also cause ulcers.
“They’re all rare,” Terezakis says.
The inflammation often can be treated with steroids or anti-viral agents, depending on the possible cause. Powers has used the potent generic steroid clobetasol, either topically or injected, and may follow that with a milder drug.
“I treat it a week or two to break the cycle,” Powers says. “Sometimes it hangs on for awhile, sometimes it hangs on forever. It depends on what’s causing it.”
Inverse Pterygium: The Not-So-Free Edge
The skin beneath the free edge of the nail is the hyponychium, also called the solehorn. The skin joins to the underside of the nail plate to create the onychodermal band, a barrier that keeps body fluids in and germs out.
This is the locale of a less-common form of pterygium: inverse pterygium, or pterygium inversum unguis. It occurs when scar tissue abnormally attaches the hyponychium to the underside of the nail and stretches forward as the plate grows out. The skin in the area is usually sensitive and even painful.
Again, doctors are not sure what causes the inflammation and scarring. It could be a hereditary condition or the result of a systemic, auto-immune, or circulatory disorder.
In some cases, inverse pterygium can be caused by an allergic reaction to acrylics used in nail enhancements or the solvents used to remove them, Powers says.
If it’s caused by an allergic reaction, “remove the underlying factor. No more acrylics” says dermatologist Powers. “If the client’s nails and skin are all inflamed, let everything heal up“
Inverse pterygium can look very much like advanced hyponychium, which is a growth of normal tissue under the nail. As with the other conditions, “We don’t know what causes it,” Terezakis says.
Servicing Clients With Pterygium
If a client has true pterygium the best service is probably nothing at all.
But first, look carefully at what you have before you. If a client comes in with what you think may be pterygium, remember that this is unlikely. Examine her or his hands for any signs of inflammation. Red itchy patches at the base of the nail may indicate an allergic reaction to acrylics or other chemicals.
Look carefully at the tissue that has grown over the nails. “Pterygium looks as though the skin has grown, not only into the nail plate, but into the nail bed,” Terezakis advises. “If it’s all around all of the nails, it’s probably not a true pterygium.”
If it looks as though the cuticle has somewhat fused over the nail, then you may really have a case of monster cuticles. People who are unable to care for themselves, such as the bedridden, have this more often.
Ask the client if she or he has had any trauma to the area for another clue. Remember that pterygium is caused by a badly damaged nail matrix.
Is the nail pitted, thin, and extremely fragile? Those are some of the signs of true pterygium.
If you do suspect the client has pterygium, Terezakis counsels, “Refer that person to a dermatologist.” You could offer the contact information of the American Academy of Dermatology (www.aad.org or (847) 330-0230), where the client can ask for doctors who know about rare nail diseases.
Never try to apply acrylic enhancements to damaged, thin nails, both Powers and Terezakis agree.
“The worst thing you could do would be to put on acrylic nails, because the nails are so fragile and so porous,’ Terezakis warns. “You have to file the top of the nail to roughen it, and the nails are already abnormal, so you’ll get some chemical absorption and you risk destroying the whole nail base. The nail is so fragile that even trying to polish it may be traumatic for some people.
“The best thing is to leave it alone,” she adds. “When in doubt, do nothing that may harm.”
Servicing Overgrown Cuticles
Though your client’s cuticles may look like candidates for a rare disease, the condition probably is not truly so dire. Instead, a patient technician can apply gentle and regular manicures to gradually improve the appearance of the client’s hands.
If the client is coming in for the first time, explain that you can’t fix the problem in one session However, regular maintenance can get it under control and keep it there.
“These clients tend to have sensitive cuticles, so you have to be careful,” says Renee Borowy of VIP Salon and Spa in Riverview, Mich. “It’s difficult to work on the first time. If the client has a routine of softening the cuticle, then it’s easier to handle.”
At Dillard’s Department Store salon in Cincinnati, technician Mary Ann En- zweiler asks clients with problem cuticles to soak for 10 minutes m white vinegar before coming in. Vinegar is absorbed by the keratin, the tough outermost layer of the dermis, and speeds up the softening process.
Enzweiler and Borowy offer the following procedures:
“The clients who were willing to work with my recommendations no longer have issues with cuticle overgrowth,” Enzweiler says.
Handling Advanced Hyponychium
At The Nail Forum chain in the Los Angeles area, owner Quinncie Do’s staff occasionally see clients whose hyponychium is somewhat advanced. Though not a true pterygium, the condition can be uncomfortable or painful.
You can offer some relief to clients by soaking and softening as suggested above, and gently pushing back the hyponychium, Do suggests.
“Advanced hyponychium is usually seen in clients with longer nail beds,” Do says. “Never use force to push back or cut, because it can tear the hyponychium and cause bleeding.”
When cleaning underneath the free edge, wrap a bit of cotton around the point of an orangewood stick and dip it into mild, soapy water, then rinse it in clear water to clean the area, Terezakis suggests.
“Roll it from side to side gently to clean, assuring that no dirt or oil is left,” Do adds.
Then, be conservative in the service.
“When trimming natural nails, always cut less to avoid damaging the hyponychium and to leave room for filing and shaping,” Do advises. “It’s always better to go back and re-trim than to have the filing injure the protruding hyponychium or, worse, cut into it.”
Borowy does apply acrylic nails on clients with advanced hyponychium, but she cautions techs never to use products containing MMA. “The MMA doesn’t release under pressure,” Borowy explains, adding that if a nail gets somehow ripped off, the results can be ugly.
If you use an electric file, try filing down the point that is at the top of some drill bits for use on the underside of the nail. That reduces the chance of hurting the hyponychium, Do advises.
Trim Kleist is a freelance writer based in San Diego, Calif.