Nail therapies

150 Pages·3.182 MB·English

by  Baran, Robert;Rigopoulos, Dimitris

NAIL
THERAPIES
Edited by
Robert Baran
Dimitris Rigopoulos
Nail Therapies
ουδε′ν ο′ ϕελος εκ των απα′ντων αγαθω′ ν εστι′, εα′ ν το υγιαι′νειν και μο′ νο απη′
Ιπποκράτης (460–370π.χ)
“If human health is missing, no other benefi t can be of any value.”
Hippocrates (460–370 BC)
Nail Therapies
Robert Baran, MD
Honorary Professor of the University of Franche-Comté,
Nail Disease Centre, Cannes, France
Dimitris Rigopoulos, MD
Associate Professor of Dermatology, Athens University,
“Attikon” University Hospital, Athens, Greece
This edition published in 2012 by Informa Healthcare, 119 Farringdon Road, London EC1R 3DA, UK.
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Contents
Acknowledgements and contributors vii
1. Anatomy and physiology of the nail unit 01
2. Abnormalities of the nail contour 04
3. Psoriasis 09
4A. Onychomycosis 17
4B. Future therapies for onychomycosis 30
5. Lichen planus 37
6 Pseudomonas infection 41
7. Herpes simplex (herpetic whitlow, herpetic paronychia) 43
8. Warts 45
9. Acrodermatitis continua of Hallopeau 50
10. Acute paronychia 52
11. Chronic paronychia 55
12. Yellow nail syndrome 58
13. Eczema 60
14. Nail fragility syndrome 62
15. Onycholysis 69
16. Onychotillomania 75
17. Nail abnormalities in oncology practice 79
18. Bowen’s disease 83
19. Squamous cell carcinoma 85
20. Melanonychia 87
21. Longitudinal erythronychia 90
22. Exostosis 92
23. Glomus tumor 95
24. Myxoid pseudo cyst (mucous cyst, ganglion) 98
25. Nail cosmetics and real nail prostheses 102
26. Onychocosmeceuticals 107
VI CONTENTS
27. Nail surgery 110
28. Complications in nail surgery 121
29. Biopsy of the nail area 126
30. Matricectomy 131
31. Removal of the proximal nail fold: Why? 133
Index 137
Acknowledgements and Contributors
Chapter 4B was kindly contributed by Chris Drummond-Main, MSc, Aditya K. Gupta, MD, PhD,
FRCPC, and Fiona Simpson HBSc, all of Mediprobe Research Inc., London, Ontario, Canada.
The medical illustrations are by Florence Richert (fl [email protected]).

1 Anatomy and physiology of the nail unit
The nail plate is the permanent product of the nail matrix. Its normal appearance and growth
depend on the integrity of several components such as the tissues surrounding the nail or peri-
onychium, the bony phalanx that contribute to the nail apparatus or nail unit and so on (Fig. 1.1).
The nail is a semi-hard horny plate covering the dorsal aspect of the tip of the digit. The nail is
inserted proximally in an invagination practically parallel to the upper surface of the skin and later-
ally in the lateral nail grooves. This pocket-like invagination has a roof, the proximal nail fold and a
fl oor, the matrix from which the nail is derived.
The matrix extends approximately 6 mm under the proximal nail fold and its distal portion is only
visible as the white semi-circular lunula. The general shape of the matrix is a crescent concave in
its posteroinferior portion. The lateral horns of this crescent are more developed in the great toe
and located at the coronal plane of the bone. The ventral aspect of the proximal nail fold encom-
passes both a lower portion, the matrix, and an upper portion (roughly three quarters of its length)
called the eponychium.
The germinal matrix forms the bulk of the nail plate. The proximal element forms the superfi cial
third of the nail, whereas the distal element covers its inferior two-thirds.
The ventral surface of the proximal nail fold adheres closely to the nail for a short distance and
forms a gradually desquamating tissue, the cuticle, made of the stratum corneum of both the dor-
sal and the ventral side of the proximal nail fold. The cuticle seals and therefore protects the
ungual cul-de-sac from harmful environmental agents.
The nail plate is bordered by the proximal nail fold which is continuous with the similarly struc-
tured lateral nail fold on each side. The nail bed extends from the lunula to the hyponychium. It
presents with parallel longitudinal rete ridges.
The nail bed, in contrast to the matrix, has a fi rm attachment to the nail plate. Therefore, its avul-
sion produces a denudation of the nail bed. Colorless but translucent, the highly vascular connec-
tive tissue containing glomus organs transmits a pink color through the nail.
Distally, adjacent to the nail bed, the hyponychium, an extension of the volar epidermis under
the nail plate, marks the point at which the nail separates from the underlying tissue.
The distal nail groove, which is convex anteriorly, separates the hyponychium from the fi ngertip.
Circulation of the nail apparatus is supplied by two digital arteries that course along the digits
and send out branches to the distal and proximal arches.
The sensory nerves to the dorsum of the distal phalanx of the three middle fi ngers are derived
from fi ne oblique dorsal branches of the volar collateral nerves. Longitudinal branches of the dor-
sal collateral nerves supply the terminal phalanx of the fi fth digit and the thumb.
Among its multiple functions, the nail provides counterpressure for the pulp that is essential to
the tactile sensation involving the fi ngers and for the prevention of distal wall tissue produced after
nail loss of the great toenail.
The nail is a musculoskeletal appendage as a part of a functional unit that is comprised of the
distal bony phalanx and several structures of the distal interphalangeal joint extensor tendon
fi bers and the collateral ligaments. All these form the enthesis (Fig. 1.2). This organ is the bony
insertion point of the ligaments, the tendons and the articular capsules. It is composed of both:
● soft tissue (ligaments, tendons, and their fi brocartilages)
● hard tissue (calcifi ed fi brocartilage, the immediately adjacent bone of the underlying trabecular
network)
Histological images confi rm the link between the different structures.
Histology permits recognition of the nail matrix and nail bed that have no granular layer,
in contrast to the upper ventral aspect of the proximal nail fold called eponychium and the
hyponychium.
The hard keratin of the nail lies perpendicularly to the nail growth axis and parallel to the surface
of the nail plate.