Chapter 17: Nail Disorders &

Surgery
Nail Entities Nail Anatomy
Surgical Nail Procedures
17
NAIL DISORDERS AND SURGERY
Nails are excellent indicators of systemic disease and may provide invaluable
diagnostic information. The nails are equally sensitive to environmental and
physical stimuli and may provide vital clues that indicate toxic exposure and
traumatic insult.
Owing to the great cosmetic value of the nail, any physical derangement to
the structure can bring the patient to your office. You should check for the
following nail presentations: discoloration, anonychia, brittleness,
hypertrophy, koilonychia, onycholysis, pitting, pterygium, onychomadesis,
splitting, striations, nail thinning, ridging, change in nail consistency, change
in nail configuration, and nail clubbing.

Nail Entities
1. Anonychia: Is the complete absence of one or usually more than one nail.
This condition is a rare congenital anomaly.
i. Caused by ischemia, frostbite, toxic and infectious states, Raynaud's disease,
Darier's disease, lichen planus, subungual neoplasm, fungal infections,
psoriasis, and injuries.

2. Paronychia: Is an infection usually accompanying onychocryptosis.

Staphlococcus is most common organism. Candida is a common pathogen
also. Cultures for bacteria and for fungi are indicated.

3. Beau's Lines: Transverse ridges in the nail plate, 0.1-0.5 mm wide by

0.1 mm deep appear in the lunula and progress forward. Beau's lines
are a sudden arrest of function of the nail matrix. The width of the Beau's
lines are directly related to the duration of the illness.
i. Caused by typhus, diptheria, syphilis, malaria, leprosy, influenza, scarlet fever,
vascular diseases, diabetes mellitus, hyperthyroidism, ACTH therapy,
psroriasis, diffuse alopecia, and exfoliative dermatitis.

4. Clubbed Digits: A characteristic bulbous deformation of the terminal

phalanges topped by marked convexity of nails, with the nail becoming
hard, lustrous and thick. As the disease progresses, advanced
clubbing and angulation of the nail results in Lovibond's angle (> 160
angulation of the nail).
i. May be subclassified as hippocratic nails, pulmonary hypertrophic
osteoarthropathy, pachydermoperiostosis, or other diseases
ii. Can be caused by: congenital heart defects, cirrhosis of the liver, chronic
diarrhea, SBE, neoplasms of the lung and emphysema. 80% of clubbing is
seen in conjunction with respiratory ailments, but it may be seen in many
nonpulmonary acquired and hereditary conditions.

5. Darier-White Disease: Similar to alopecia areata. This condition will cause

changes such as red and white longitudinal streaks that run the length of the
nail.

6. Eczematous Conditions: Many types of eczematous dermatitis such as

atopic and contact dermatitis frequently affect the nail folds causing
damage to the nail matrix. As a result, many changes 'to the nail plate occur,
such as Beau's lines, onychorrhexis, subungual hyperkeratosis, and
onycholysis. Nail color may change to yellow, green, grey, or black.

7. Onychomycosis: Fungal infections are common, usually caused by

dermatophytes. In the cases of monilia and yeast it is reported that
onycholysis will develop without destruction of the nail plate. Other diseases
mimic this condition, such as psoriasis.
i. Distal and lateral onychomycosis: Most common type, caused by T.
rubrum, T. mentogrophytes, and E. Floccosum.
ii. Proximal subungual onychomycosis: caused by T. rubrum, T. megnini, T.
schoenleinii, and T. tonsurans.
iii. White superficial onychomycosis: usually T. mentagrophytes and mold
fungi
iv. Diagnosis by KOH prep and growth on Sabouraud's agar

8. Glomus Tumor: Neoplasia of the arteriovenous shunts (Suquet-Hoyer

canals) in the nail beds that constitutes the glomus bodies leads to a purplish
tumor that causes extensive pain. The nail bed will appear as a blue-red
distortion and the nail plate can have variable distortions. The lesion may
be tiny and colorless.

9. Green Nails: Usually caused by a local Pseudomonas infection or Candida

albicans. Pseudomonas produces a green pigment called pyocyanin.

10. Keratoacanthoma: This may develop in the nail beds with serious
consequences to the nail and subungual structures. The lesion appears
suddenly, ulcerated, and both clinically and histologically resembles
squamous carcinoma. Underlying bone may be involved.

11. Koilonychia: Means spoon shaped nails and describes a characteristic

deformity in the form of a concave shape.
i. Occurs with hypochromic anemia, Plummer-Vinson syndrome,
thyrotoxicosis, Raynaud's disease, gastrointestinal disorders, nail bed
tumors, and syphilis.

12. Leukonychia: A transverse spot or striation porcelain white in color of

the nail plate. There are 5 types:
i. Leukonychia punctuate (pinhead spot): associated with psoriasis, dyshidrosis,
typhus, scarlet fever, measles, arsenic and lead poisoning and
microtraumas.
ii. Leukonychia striata (transverse): looks like Mee's lines and found with
scleroderma.
iii. Leukonychia totalis (entire nail): Seen in leprosy, hypochromic
anemia, arsenical poisoning, cachexia, and Bart-Pumphrey Syndrome.
iv. Partial Leukonychia (nail is all-white but has a distal pink band) As found in
Hodgkin's disease, chilblains, metastatic Ca, and leprosy.
v. Longitudinal Leukonychia (longitudinal white stripes): Found in Darier's
disease and arsenic poisoning.

13. Lichen Planus: Will result in atrophy of the nail plate and pterygium
formation, which is considered pathognomonic for the disease.

14. Malignant Melanoma: Acral lentiginous melanoma is the most dreadful of

malignancies found under or around the nails. When the melanotic whitlow
is present, there is an elevation of the nail that can be mistaken for glomus
tumor, subungual exostosis, or profuse granulation (see chapter 13,
Dermatology: Malignant tumors)

15. Mee's Lines: Is an eponym for horizontal striations that appear in the
nails as a consequence of arsenic and thallium poisoning.

16. Onychauxis: This is the thickened, elongated, raised irregular nail. The
color can be changed from white to a mixture of green, yellow, brown, or
black, all of which may obliterate the lunula.
i. Can be caused by trauma, fungal infection, nutritional disturbances, circulatory
disorders, acute rheumatic fever, secondary syphilis, TB, psoriasis, ichthyosis,
eczema, hyperuricemia, RA, venous stasis, hyperglycemia, hyperthyroidism,
leprosy, peripheral neuritis, tabes dorsalis, and scleroderma.

17. Onychogryphosis: Is an exaggeration of onychauctic condition.

18. Onychoheterotopia: Means ectopic or abnormal position of the nails.

19. Onychomalacia: Refers to softness of the nails and is synonymous with

hapalonychia.

20. Onycholysis: Detachment of the nail bed from the overlying plate
creates a space between nail plate and nail bed in which keratin forms. This
occurs in numerous conditions:
i. Due to trauma, contact dermatitis due to nail polish, cement and topical drugs,
fungal infection, Pseudomonas infection, psoriasis, hyperthyroidism,
pregnancy, iron deficiency anemia, lichen planus, and many others.

21. Onychomadesis: The shedding of nails from the proximal to the distal
free edge. The pathology in this condition involves lesions to the matrix and
the hyponychium.
i. Due to epilepsy, peripheral neuritis, peripheral thrombosis, embolic
occlusions, diabetes mellitus, syphilis, hemiplegia, syringomyelia, and many
others.

22. Onychorrhexis: Means the breakage of nails, the nail becoming thin
and fragile with exaggerated dermal epidermal subungual sulci.
i. Due to hypochromic anemia, hypocalcemia, lichen planus, RA,
radiation, arsenic and lead poisoning, leprosy, and syphilis.
23. Onychophagia: Means nail biting.

24. Onychoschizia: The nail becomes very fragile, and as a result, distal
splitting of the nail occurs. There are two or more laminations overlying
each other. The nail appears multilayered.
i. Due to acromegaly, chronic eczema, metabolic acidosis, peripheral nerve
lesions, trauma, infectious diseases, hyperthyroidism, and hypochromic
anemia.

25. Pterygium Ungium: Overgrowth of the eponychium so that the

lunula and much more of the nail plate is covered by a wing
(pterygium) of soft tissue.
i. Due to scleroderma, Raynaud's disease, vasospastic disorders, leprosy,
dermatomyositis and peripheral neuritis.

26. Squamous Cell Carcinoma: This occurs under nail plates usually as a
result of a progression from squamous cell Ca in situ (Bowen's disease). It
must be differentiated from keratoacanthoma. (see Dermatology section)

27. Splinter Hemorrhages: These are caused by capillary fragility in the

longitudinal vessels of the nail bed.
i. Due to: scurvy, SBE, CHF, vasculitis, tetanus, hemophilia, and
hypoparathyroidism

28. Periungual Fibroma: May be either acquired or congenital.

Congenital fibromas are often associated with tuberous sclerosis, a
disorder characterized by periungual fibromas, mental retardation,
seizures, and adenoma sebaceum. (see Dermatology section)
 NOTE* Changes in nail color are markers for disease of blood, endocrine system,
cardiovascular and peripheral vascular systems, and toxicity of drugs,
chemicals or metals:
a. Yellow nails: may suggest Addison's disease or diabetes mellitus b. Blue
nails: may be a sign of cyanosis or heavy metal poisoning c Green nails:
Pseudomonas infection
d. Black-brown discoloration: may be normal pigmentation, Peutz Jaegher disease
(also have brown macules on the palms and soles), Addison's disease,
junctional nevus, or melanoma
e. White nails: may be hereditary, a sign of anemia, fungal infection, Bart-
Pumphrey Syndrome
f. White striae: arsenic poisoning or drug toxicity
g. White spots: injury to the nail plate, psoriasis
h. Alternating white lines with pink nail (Muercke's lines): may suggest
anemia, chronic liver disease, nephrotic syndrome, or Darier- White disease
i. Reddish nails (or combination of red/white/brown): may be signs of
localized neoplastic disease

Nail Anatomy
1. The matrix is a stratified epithelium that produces hard keratin. Proximal
matrix forms the superior nail and the distal matrix forms the lower nail.
2. Hyponychium is an epithelial layer of the nail bed and really does not
produce much nail plate keratin. It does help, however, in subungual debris
production.
3. Predominantly nail develops from the matrix, but the proximal nail fold,
lateral grooves, bed, and hyponychium can all be onychogenic.
4. The nail plate can be separated into 3 zones with predominantly
different beginnings. The uppermost layer is generated by the proximal
nail fold, the plate by the matrix, and the deepest section of the nail plate
is contributed to by the nail folds and bed.
5. The nail matrix is found on the proximal slope of the distal phalanx and
extends medial and lateral to the phalanx. The germinal matrix extends
laterally as far as the width of the nail plate just distal to the lunula and with
the same curvature. Proximally it extends to 1 1 /2 to 2 1 /2 times the length
of the visible lunula.
6. The lunula is a white semi-lunar area corresponding to the anterior
matrix.
7. The nail bed consists of the hyponychium and corium over the matrix.

Surgical Nail Procedures

Nail problems that dictate surgical intervention are abscess,
persistent pain, regrowth or spicule development. Chronic nail
infections may lead to OM due to the close proximity of the nail and the
dorsum of the proximal phalanx.
1. Phenol and Alcohol Chemical Matrixectomy:
i. Should always do preoperative CBC/Diff and FBS.
ii. This procedure has been done in well controlled diabetics, but should be
avoided in patients with PVD.
iii. Phenol and lidocaine are teratogenic and should not be used in the
pregnant patient.

2. Sodium Hydroxide Matrixectomy:

i. Acetic acid used to neutralize
ii. Apply 10% NaOH till capillary coagulation
iii. Same criteria apply as for Phenol-Alcohol procedure

NOTE* The following are cold steel procedures. The indications are: chronically
recurring ingrown toenail, failed Phenol-Alcohol procedure, chronic
hypertrophic ungual labia, subungual exostosis in combination with
dystrophic, hypertrophic or mycotic nail, patient in whom chemical or
thermal bum is contraindicated (diabetes?), excision and biopsy of nail/nail
bed/matrix tissue, in conjunction with bunion procedures, patients who will
not comply with postoperative regimen of Phenol-Alcohol procedures,
cosmetic reconstruction of deformity, and surgeon's preference.

3. Frost Procedure:
i. For ingrown toenail with "proud flesh" and chronically hypertrophic
ungual labia
ii. Excise a piece of matrix through an inverse "L" shaped incision
iii. Nail and matrix along the problem labia is excised with the second
incision
iv. Closure is with suture after curettement of the phalanx
v. Due to the tissue necrosis that occurs, this procedure requires both
primary and secondary wound healing, therefore of little advantage over
non-cold steel procedures

Figure 1: Illustration of Frost Procedure

Clinics in Podiatric Medicine and Surgery: Nail Disorders, Saunders, April 1989, Volume 6:2, with
permission

4. Zadek Procedure: Based on the premise that excision of the nail bed
was not necessary in preventing regrowth of the nail, therefore Zadik
directed his attention only to the nail matrix.
i. The incisions utilized are perhaps this procedures greatest contribution
ii. Utilized more for total nail excisions in the lesser digits
iii. Not recommended for the difficult onychauxic nail (where nail bed
removal may also he necessary)

Figure 2: Illustration of Zadek procedure

Clinics In Podiatric Medicine and Surgery: Nail Disorders, Saunders, April 1989, Volume 6:2, with permission

5. Kaplan Procedure: The most well documented toenail surgery in the

literature. Unlike the Zadek, the Kaplan stressed the need to remove both
the nail matrix and nail bed.
i. This procedure is indicated for correction of severely onychauxic,
mycotic, or chronically deformed or ingrown toenails. It is also the
procedure of choice when the former are combined with painful or deforming
subungual exostosis or osteochondroma.
ii. The original procedure describes an "H" incision carried out at two
tissue depths. The proximal half of the "H" includes only the nail matrix and
stresses the preservation of periosteal tissue. The distal half of the "H" is
carried directly down to the distal phalanx and involves stripping of the nail
bed and thus exposing the distal phalanx.
iii. A modified Kaplan has been described, whereby, the "H" incision is replaced by
the Zadek-type incision. This allows for maximum exposure of the nail
matrix area.

Figure 3: Kaplan Procedure

Clinics In Podiatric Medicine and Surgery: Nail Disorders, Saunders, April 1989, Volume 6:2, with permission
 Figure 4: Wound closure for Winograd Procedure
Clinics In Podlatric Medicine and Surgery: Nail Disorders, Saunders, April 1989, Volume 6:2, with
permission

6. Winograd procedure: Dr. Winograd was the first to describe a linear

incision into the posterior nail fold with excision and curettage of the nail
matrix tissue. The incision he discribed is the same used today.
i. Contrary to popular belief, the most important component of wedge
resection is wound closure and not whether the entire matrix is
encompassed within the width of the tissue ellipse.
ii. When a modified Winograd is considered, 3 preoperative components
must be considered:
 must be sure that an adequate amount of soft tissue exists for good
wound closure.
 the length of the ellipse must be at least 3 times the width
 wound closure is by primary intention (preferably)

7. Suppan Procedure:
i. Frees the eponychial fold and removes the nail
ii. Visualizes the nail matrix proximally
iii. Cut the lateral borders and the anterior borders
iv. Hold tag and remove the proximal attachment
v. Curette down to bone into the lateral cul de sac

8. Complications From Nail Surgery:

a. Recurrence
b. Excessive drainage
c. Excessive bleeding
d. Poor technique and excessive tissue destruction e. Infection
f. Exuberant granulation tissue
g. Insufficient amount removed
h. Soft tissue migration upward to the dorsum of the toe