Brittle Nail Syndrome: Treatment
Options and the Role of the Nurse
ni
Richard K. Scher
Philip Fleckman
Bonita Tlilumbas
Len McCoUam
Phyllis Enfanto
Dermatology jut/ses cue
uniquely poMioned to am ;v
brittle nail ryndrome, i
midtifactorcl disorder, m
injunction with a t)hmci \n,
and to help develop a
therapeutic plan 0 na
underlying causes a^'e mmrijie
dermatology nurses car. [^uptoi
patients in nail care a id ayy^Si
the dermatologist in pr
treatment compUajice,
Objectives
This educational activity is designed for nurses and other health care
professionals who give direct care and education to patients regarding nail
healtli. An evaluation follows this offering and is designed to test the reader's
achievement of the objectives listed below. After studying the information
presented in this article, the nurse will be able to:
1. Discuss the importance of nursing interventions in the area of
brittle nails and list three causes of brittle nails.
2. Perform an assessment of patients' nails.
3. Develop a plan of treatment and care for patients with brittle nails.
B
rittle nail syndrome is a condition that affects approximately
40 million Americans, occurRichard K. Sdier, MD, FACP, is a fa
ring more often in women
of Clinical Dermatobg^, Department of
than men (Scher & Bodian, 1991). It is
Dermatology, CoU^e cfPhysidam and Surgeons,
chEiracterized by excessive longitudiColumbia Unwersity, New %rk, NY.
nal ridging (onychorrhexis), horizonPhilip Fleckman, MD, is a Professor, tal layering (onychoschizia) of the disDepartment cfMedicine (Dermatohg^), Umoenity
tal nail plate, roughness of the nail
ofWashmgjon, Seattle, WA.
plate surface, irregularity of the distal
Bonita lidumbas, RN, is a Dermaijoh^ Nmse,
edge of the nail plate, and loss of nail
Department cfDermatoh^, Collie ofPhysidnns
flexibility
(Cohen & Scher, 1992;
and Surgeons, Columbia University, New Wrk, NY.
Heckman, 1999). Although the finLen McCoUam, RN, is a Licensed Estketidcin,
gernail may appear to serve only a
Department cf Medicine (Dermatobg^), University
cosmetic purpose, it in fact has severofWashingtm, Seattle, WA.
al major functions, including protectFli)dlis En&nto, MS, RN, isaManagtngRirtJier,
ing the fingers, contributing to tactile
EHC Communications, Inc., DobbsFeny, NY
sensation, and enhancing manipulaNote: Same therapies may he "cfflabel."Health
tion of objects. It is also an important
care professioruds must be co^mxnt of Ms.
communication tool (American
Conflict of Interest: Dr. Sdier is a consultant,
Academy of Dermatology [AAD]
speaker, and investigatorfarMerz Pharmaceuticals
Guidelines/Outcomes Committee
and otherpharnmceuUcal companies.
Task Force, 1996; Noronha &
Dr. Fleckman has consulted or acted as an investiZubkov, 1997; Tosti & Piraccini,
gator in studies for Brystol Myers-Squibb, Cell^
2000). Nor axe nail abnormalities triv(Glaxo), Chantal, Exovir, Hoedist-RousseU
ial. They can be indicative of medical
Dermik/Aventis, Johnson & Johnson, Medids,
Navartis, andP/k^.
conditions ranging from minor
injuries
and infections to severe sysAll authors have received an horwrariumfartheir
temic diseases to hereditary disorders.
participation in the article.
OERMATOLOGY NURSING/February 2003/Vol. 15/No. 1
In addition, nail disorders may
aifect patients psychologically, causing them to hide their hands and feet
and shy away firom social interaction
(AAD,
1996; Lubach, Cohrs, &
Wurzinger, 1986; Tosti & Piraccini,
2000). In some societies, nail problems may also aifect occupation and
employability. Patients may not realize how important their nail health is
until they are affected by brittle nails.
Role of the Nurse
Since many persons with nail disorders seek help firom a dermatologist, the dermatology nurse is uniquely positioned to assess these patients
and to collaborate with the dermatologist to develop the best possible plan
of care for each one. Effective management of nail abnormalities will
prevent
further
complications,
improve patient self-image, and perhaps reduce health-related costs.
The nurse's role encompasses
assessing nails and providing a differential diagnosis of a nail complaint, as
well as patient support and education
in treating the condition and prevent-
15
DERMATOLOGYN
Table 1.
Role of the Nurse in Managing a Patient with Brittle Nails
1.
2.
3.
4.
5.
6.
7.
8.
9.
ing further complications (see Table
1). The nurse should in fact integrate
a nail assessment into a standard
patient evaluation whenever appropriate because many skin disorders
and other disease states may give rise
to nail involvement. In addition to
observing the nails of toes as well as
fingers, the assessment should include
a history to determine if there are any
environmental, occupational, systemic, inherited, or cutaneous conditions that could suggest a cause.
During the assessment, it is vital to
remain professional and empathetic,
as many patients may be embarrassed by their nail condition and
accustomed to hiding their hands and
feet; some patients may be concerned
that the condition is contagious. Once
an etiology is detennined, the nurse
can collaborate with the physician to
develop and implement a treatment
plan.
Assess nails.
Obtain a history to determine any causative factors.
Perform physical inspection.
Be empathetic to patient's feelings about the nail disorder.
Emphasize importance of nail hydration.
Collaborate with prescriber on plan of care.
Educate patient on treatment protocol.
Encourage patience with treatments to enhance compliance.
Set realistic expectations for time to improvement based on slow nail growth
(approximately 3 mm per month for fingernails; 6 months to grow out).
Table 2.
Etiology of Brittle Nails
Occupational/Environmental
Systemic
Bean sheiiers
Butchers
Chemists and laboratory workers
Engravers
Etchers
Giazers
Hairdressers
Hat cleaners
Health care workers (dental hygenists,
dentists, nurses, physicians)
Homemakers
Musicians
Photographers
Plasterers
Porcelain workers
Radio workers
Shoemakers
Wet work (bartenders, cooks,
dishwashers, laundry workers,
waitresses)
Wood workers
Workers exposed to microwave
radiation
Aging
Arsenic intoxication
Bronchial carcinoma
Collagen vascular diseases
Diabetes mellitus
Eating disorders
Endocrine disorders (hypothyroidism,
hyperthyroidism, gout,
hypoparathyroidlsm)
Infections (syphilis, tuberculosis)
Iron deficiency anemia
Malnutrition
Plummer-Vinson syndrome
Polycythemia vera
Pregnancy
Radiation
Raynaud's phenomenon
Sarcoidosis
Sjogren's syndrome
Systemic amyloldosis
Vitamin deficiencies (A, B6, C)
Prinrnty Derinatol<^ic
Miscellaneous
Alopecia areata
Atopic dermatitis
Chronic inflammation
Darier's disease
Ectodermai dyspiasia
Eczema
Ichthyosis
Lichen planus
Onychomycosis
PItydasis rubra pilaris
Psoriasis
Radlodermatitis
Congenital
Familial
Idiopathic
Neoplasms (warts, squamous cell
cancer, basal cell cancer, Bowen's
disease, maHgnant melanoma)
Twenty-nail dystrophy
Sources: Baroletti, Winsor, Fanikos, & Hartman (2002); Kechijian (1985); Silver &
Chiego (1940); Scher & Bodian (1991).
16
Etiology of Brittle Nail Syndrome
i
The possible causes of brittle
nails can be divided into four main
categories: occupational/environmental, systemic, primary dermatologic, and miscellaneous inherited
and acquired factors (Kechijian, 1985;
Scher & Bodian, 1991) (see Table 2).
Occupational/Environmental causes.
The most common cause of brittle
nails is dehydration of the nail plate as
a result of occupational or environmental exposure to damaging agents
(Fleckman, 1997; Kechijian, 1985).
Any chemical or mechanical trauma
that affects or damages the nail will
decrease its ability to retain water and
result in nail dehydration (Scher &
Bodian, 1991). Common culprits in
dehydration include alkaline liquids,
acetone, organic solvents, and frequent handwashing. Additionally,
direct trauma to the nail plate can
occur from nail biting and such everyday activities as typing, dialing a telephone, or playing a musical instrument; even grasping, prying, or scraping can be sufficiently traumatic to
lead to dehydration (Kechijian, 1985;
Scher & Bodian, 1991).
OERMATOLOGY NURSING/February 2003/Vol. 15/No. 1
Tahle 3.
Common Nail Symptoms Relate i to Environmental or Occupational Exposure
Nail Disorder/Symptom
History/Physical Exam
Mam^ment
Brown nails
History of exoosure to chemicals (for
example, wood worker), burnt sugar
(for example, bakers), e^tc.
Protect hands during work.
Green nails
May be inflamed.
Caused by infection with pseudomonas
or aspergillus.
Seen in bartenders, restaurant workers.
Treat underlying infection.
Hematoma
Subungual hemorrhage
Painful
Recent Injury
Avoid trauma.
Protect nail.
Puncture nail plate to permit drainage.
Hypertrophy of toenail
Great toe nail becomes thicker and
longer than others.
May be due to fungal infection,
psoriasis, pachyonychia congenita,
or injury.
Treat underlying disorder.
Avoid trauma.
Ingrown toenail
Pain, inflammation at lateral nail fold
of toe.
Due to compression from tight footwear,
hyperhidrosis, improper trimming of
nail plates.
Use proper footwear.
Rotate shoes.
Use protective foot powder.
Trim toenails straight SK^ross.
Leukonychia punctata and transverse
striate teukonychia
White spots or lines.
Single or multiple.
Seen frequently in children.
Caused by minor injury of matrix.
Avoid trauma.
Paronychia
May be acute or chronic.
Red, tender swollen nail folds (proximal
and lateral).
Can be bacterial or fungal.
May be due to Staphylococcus aureus,
herpetic whitlow, Candida albicans.
Systemic antibiotic.
Topical or systemic antifungal.
Topical steroid to proxirr^l rmil fold,
drying agent beneath the proximal
nail fold.
Short uneven nails, swelling, and
peeling of nail folds
History of nail biting, picking, or rubbing.
Treat underlying anxiety or tension.
Splinter hemorrhages
Red brown linear marks parallel to the
longitudinal axis of the fingers.
History of trauma.
Has been associated with bacterial
endocarditis and sepsis.
Avoid trauma.
Evaluate temperature and for signs of
infection.
Sources: Holtzberg & Walker (1985); Kpea & Scher (1987); Lieber & Dotz (1986); Mayeaux (2000); Noronha & Zubkov (1997);
Rich (1998); Sinclair (1997).
The normal water content of the
nail is approximately 18%. When
hydration drops below 16%, the nail
becomes brittle (Scher & Bodian,
1991). Frequent handwashing causes
the nail plate to expand and contract
many times as the nail absorbs and
loses water. That places continual
strain on the protein structures and
onychocyte bridges, resulting in
weakening and eventually destruction of the protein links between the
OERMATOLOGY NURSING/February 2003/Vol. 15/No. 1
cells that make up the nail. The structure loses the ability to retain water;
the nail consequently becomes brittle
and susceptible to splitting, cracking,
and peeling.
Such consequences are a signifi17
OERMMOLOGf
cant problem in occupations that
require frequent handwashing; homemakers, health care workers, food
preparers, and laboratory workers are
at particular risk. Excessive use of nail
polish removers containing such
harsh chemical agents as acetone and
acetates may cause dehydration of the
nail, leaving it dry and fragile. As the
polish is removed from the nail plate,
water is removed along with it, exacerbating dehydration and resultant
brittleness (Scher & Bodian, 1991).
Dehydration can also occur through
simple evaporation and may be worsened by dry climates, cooler temperatures, soaps, and detergents
(Uyttendaele, Geier, & Scher, in
press). Nail symptoms associated with
occupational or environmental etiologies are summarized in Table 3.
Systemic causes. Many systemic
conditions can result in brittle nails.
Aging ha^ been associated with brittle
nails. Atherosclerosis of the small
arteries will decrease blood flow to
the nail matrix and significantly
reduce the nail's rate of growth and
flexibility (Kechijian, 1985). Age also
produces general changes in nail
growth patterns. Longitudinal ridges,
which contribute to brittleness, may
appear as early as the late 20s and
become more pronounced with
increasing age (Lieber & Dotz, 1986).
Additionally, nails thicken and
become more opaque in the elderly;
despite their thickness, such nails may
be brittle because of accompanying
decrease in flexibility.
Poor nutrition is another cause of
poor nail health. In some patients,
brittle nails may be an early sign of
eating disorders, but brittleness can
also occur with general malnutrition
not associated with anorexia or
bulimia. Deficiencies of vitamins A,
B6, and C may also reduce nail
strength and promote brittleness
(Scher & Bodian, 1991).
Brittle nails can be induced by
several systemic disease states, many
of them chronic. The brittleness is a
secondary sign of underlying pathology, which may include a long-stand18
ing hypoxic state in which the nail
bed does not get an adequate blood
supply, as in clubbing that occurs
with cardiovascular or pulmonary
disease, or hormonal changes, as are
seen during pregnancy. Nail changes
may affect shape, color, thickness,
and/or brittleness. Some systemic disease states are associated with specific
nail changes, such as Lindsay's halfand-half nails, which occur in patients
with chronic renal failure, whereas
other changes are present in many
underlying disorders. For example,
koilonychia, a condition in which the
nail becomes brittle and spoonshaped, may result from iron deficiency, Raynaud's disease, thyroid
dysfunction, trauma, PlummerVinson syndrome, or hemochromatosis, among other possibilities
(Kpea & Scher, 1987; Lieber & Dotz,
1986; Noronha & Zubkov, 1997) (see
Table 4).
Primary
dermatologic
causes.
Several dermatologic conditions may
contribute to nail disorders. Pitting of
the nail is associated with nail psoriasis, alopecia areata, or eczema
(Sinclair, 1997). Roughness of the nail
with increased longitudinal ridging
and a thin nail plate occurs in psoriasis, alopecia areata, and/or lichen
planus (Noronha & Zubkov, 1997;
Rich, 1998; Tosti & Piraccini, 2000).
As many as 50% of patients with psoriasis have some nail involvement;
that almost always accompanies other
dermatologic
manifestations.
Psoriatic nail changes can include
changes in color to yellow or tanbrown, separation of the nail plate
from the distal bed (onycholysis), or
development of subunguaJ debris.
The most common nail disorder
by far is onychomycosis, also called
tinea unguium. This fungal infection
of the nail unit accounts for up to 50%
of nail dystrophy (Scher, 1994). The
infection is commonly acquired in
locker rooms and swimming pools or
from soil. Fungal nail infections vary
in appearance, depending on the
organism that causes the infection.
Among the red fiags for onychomy-
cosis are separation from the underlying nail bed, subungual debris, thickening, flaking, and changes in color.
The infection rarely subsides spontaneously, and treatment is almost
always necessary (see Table 5).
Miscellaneous causes. This category
includes both inherited and acquired
nail abnormalities. Inherited nail disorders tend to affect either the nail
matrix or the nail bed (Lieber & Dotz,
1986; Rogers, 2002), as in anonychia
in which the nail matrix is absent at
birth. Twenty-nail dystrophy or trachyonychia, which can be congenital
or acquired and often affects all nails,
is characterized by thin, fragile, lusterless nails with rough surfaces and
excessive longitudinal striations
(Noronha & Zobkov, 1997). Brittle
nails are sometimes not environmentally caused but instead are familial or
idiopathic. Both malignant and
benign tumors can affect the nail as
well; abnormalities can result from
peri and subungual warts, squamous
cell carcinoma, basal cell carcinoma,
and malignant melanoma, among
other causes (Lieber & Dotz, 1986)
(see Table 6).
Patient Assessment
Each nail unit is made up of the
nail matrix, nail plate, proximal and
lateral nail folds, cuticle, and nail bed
(see Figure 1). Any assessment of the
nail should include examination of
the entire nail unit, along with a complete skin exam. Whether or not the
patient presents with a primary nail
complaint, the dermatology nurse
should be aware of any obvious nail
changes and look for subtle changes
as well. To evaluate presenting symptoms and nail changes, the nurse
should both obtain a history and perform an inspection of the patient's
skin, hair, and nails.
History. The patient history
should address whether the nail
changes are new or chronic, if any
recent trauma or insult has occurred,
if the patient has had relevant occupational or environmental exposures,
and if an illness or disease may be
OERMATOLOGY NURSING/February 2003/Voi. 15/No. 1
faoie 4
Nail Disorders Associated w th tSystemic Disease
History/Physicai Ex.am
Nail Disorder/Symptom
Disease
Abnormal dilated capillary loops
Periungal erythema, svve ling color
changes, scaling, and abnorr-al
cuticles.
Dermatomyositis, scleroderma, lupus
erythematosus, Raynaud's disease.
Azure lunula
Blue colored lunula (nail crescent).
Wilson's disease
Beau's lines
Transverse linear depressions in nails.
Severe systemic disorder including
infection, metabolic illness, or trauma;
many other systemic diseases.
Clubbing
Angle of nail plate and proximal nail fold is
straightened or greater than 180 degrees.
Hypoxic states usually due to
cardiovascular or pulmonary disease.
Koilonychia
Nail is spoon shaped (depressed
center), thin, and brittle.
Anemia, thyroid dysfunction, trauma,
Plummer-Vinson disease, hemochromatosis, Raynaud's disease, and
other causes.
Lindsay's nails
Proximal half is opaque white and distal
half is pinkish brown.
Chronic renal failure.
Mee's lines
Transverse narrow white lines on the
nail plate.
Arsenic poisoning. Many other severe
systemic insults or drugs.
Muehrcke's lines
Paired, transverse narrow white bands
parallel to the lunula.
Hypoalbuminemia. Chronic liver
disease.
Onycholysis
Separation of distal nail from the nail bed.
Thyroid disease, psoriasis, and other
causes.
Periungual fibrokeratoma, acquired
Brown to flesh-colored grain-shaped
growths in periungal groove or
elsewhere in the nail unit.
Tuberous sclerosis, idiopathic.
Shell nails
Nails are whorled like seashells.
Bronchiectasis
Terry's nails
Nails are completely white and opaque
in color with a narrow pink distal margin.
Severe systemic disease such as
cirrtiosis or congestive heart failure,
diabetes. Age >50. Can be hereditary.
Yellow nail syndrome
Nail color is yellow, growth is
decreased, and nail curvature and
thickness are increased.
Lymphedema, bronchiectasis, sinusitis,
pleurai effusion, thyroid disease, and
others.
Sources: Albert (1996); Holtzberg & Walker (1985); Kpea & Scher (1987); Lieber & Dotz (1986); Mayeaux (2000); Noronha &
Zubkov (1997); Rich (1998); Sinclair (1997); Tosti & Piraccini (2000).
present that might have precipitated
or contributed to the changes (Albert,
1996). Questions asked during a history should include but not be limited
to the following:
•
When did you first notice the
problem?
•
Did the disorder begin abruptly
DERMATOLOGY NURSING/February 2003/Vol. 15/No. 1
or gradually?
How long have you had the disorder?
Has the disorder been present
since birth? Since childhood?
Is the disorder constant or intermittent?
Do you have a history of previ-
ous skin, hair, or nail disorders?
Do you have any other hair or
skin disorders?
Have you had any previous medical treatment or nail surgeries?
Do you have a family history of
nail disorders?
Have you had any recent trauma
19
OERMATOUKi
Table 5.
Nail Disorders Associated with Primary Dermatologic Diseases
Dermatologic Disorder
History/Physical Exam of Nails
Management
Alopecia areata
Transverse linear irregular pitting of
nails. May result in koilonychia,
onychorrhexis, and trachyonychia
(rough nails). Patches of hair loss.
Intralesional injection. Systemic
steroids.
Atopic dermatitis
Roughening of nail surface, pitting.
Topical steroids; calcineurin inhibitors;
tar; moisturizers.
Lichen planus
Thinning, brittleness, ridging, and
scarring. Pruritic, purple, polygonal
papules.
I Must diagnose and treat early with
j topical, intralesional, or systemic
steroids.
Hyperkeratosis of nail bed, yellow
brown discoloration, onycholysis.
Caused by fungal infection of the nails;
can be single, multiple, hand, or foot.
! Systemic and/or topical antifungal
I therapy.
Pitting, longitudinal ridging, yellowbrown (oil) spots, thickening, increased
pliability, onycholysis. History of
cutaneous psoriasis.
; Topical steroids. Intralesional injection,
\ Systemic therapy,
Onychomycosis
Psoriasis
Sources: Albert (1996); Habif (1990); Kechijian (1985); Lieber & Dotz (1986); Mayeaux (2000); Noronha & Zubkov (1997);
Rich (1998); Sinclair (1997); Tosti & Piraccini (2000).
Table 6.
Miscellaneous Causes of Nail Disorders
Nail Disorder/Symptom
Cause
History/Physical Exam
Absence of nails
Nails missing since birth.
Anonychia
Angular lateral nail plate growth of the
toenail
Transverse ridging, discoloration,
thickening, and onycholysis.
Congenital malalignment
! Excessive longitudinal striations
Nails are also fragile. May occur in ali
20 nails.
Twenty-nail dystrophy
(trachyonychia)
I Flesh-colored to pink nodule on nail
j fold. Often produces a longitudinal
j trough in the surface of the nail plate.
Cyst on proximal nail fold expresses
mucin when punctured.
Mucous cyst
May displace or compress nail plate.
Benign skin neoplasm; wart
Leakage of pigment into the proximal
and lateral nail folds.
Possible malignant melanoma
I Hyperkeratosis of the nail beds and
! palmoplantar skin
Yellow-brown discoloration. Gross
thickening.
Palmoplantar keratodermas
I Longitudinal pigmented bands
Band from cuticle to free edge.
Malignant melanoma; nevus; benign
melanotic macule
I
^
_
,.—^
___—™_...—™™.
i Growth near nail fold and nail bed
Hutchinson's sign
Sources: Kechijian (1985); Kpea & Scher (1987); Lieber & Dotz (1986); Mayeaux (2000); Noronha & Zubkov (1997); Rich
(1998); Sinclair (1997); Tosti & Piraccini (2000).
20
DERMATOLOGY NURSING/February 2003/Vol. 15/No. 1
I
if PI
ries
•
to the area? Crush injury? Toe
stubbing?
Have you noticed any precipitating or alleviating factors?
Have you had occupational
exposures to chemicals, solvents,
frequent handwashing?
Do you have manicures and
pedicures?
What nail products do you use?
What footwear do you use?
What is your diet like?
What happens to your hands
when you go outside in cold
weather?
Do you have any other medical
problems, such as anemia, arthritis, or immunological or thyroid
disorders?
Physical examination. The physical
examination should be systematic and
include a complete skin, hair, and oral
mucosal examination. Examine both
the hands and feet (Albert, 1996;
Lieber & Dotz, 1986; Mayeaux,
2000). Use a magnifying glass and pen
light as needed. Make sure you make
a note of the specific nails that are
involved and their shape, contour,
and color. Note also any superficial
changes such as pitting and changes
involving the nail plate. The examination should follow these simple steps:
Remove all nail cosmetics.
Have patient relax fingers and
toes.
Inspect all 20 nails systematically.
Check the integrity of the cuticle
and condition of the proximal
nail fold, the nail plate, and the
subungual area.
• Evaluate the nail thickness, consistency, color, and surface characteristics.
•
Check for onycholysis.
• Using a pen light, illuminate the
nail from beneath the finger tip
or corresponding toe area.
Determine whether any lesion
found blanches with pressure.
•
Evaluate for concomitant problems in skin, hair, and mucous
membranes; check for immunologic disorders.
Table 7.
r eatment Protocol for Brittle Nails
1.
2.
3.
4.
5.
6.
7.
Treat unc)e ving cause or disease, if present.
Eliminate jreciptating factors and agents - avoid dehydrating soaps,
solvents, disinfectants, and frequent exposure to water.
Wear protective gloves (cotton gloves beneath rubber gloves).
Practice good nail care.
Replenish moisture.
Apply nail enamel no more than weekly.
Take oral biotin.
Sources: Cohen & Scher (1992); Colombo et al. (1990); Gehring (1996);
Tosti & Piraccini (2000).
Figure 1.
The Nail Unit
Differential diagnosis. Once the
history and physical examination
have been completed, use the information from them to narrow down
the possible causes of the patient's
brittle nails. Attempt to determine
whether changes are occupational,
associated with systemic or primary
cutaneous disorders, or inherited. All
of this information will of course assist
in developing a plan of care specific
to the patient. Tables 3 through 6
summarize many of the more common nail changes that may be found
on physical evaluation, along with
possible causes and some management options.
Treatment Options
The dermatology nurse and the
physician should coUaboratively
develop a treatment plan for the
patient. Treatment for brittle nails
should be planned systematically (see
Table 7). When considering the most
appropriate treatment for brittle nails,
it is important first to eliminate any
exacerbating environmental or occupational factors and to maximize the
treatment of contributing underlying
disease states. Some primary nail disorders, such as onychomycosis, will
require topical and perhaps systemic
treatment with prescription medications to correct the problem.
Approaches to treatment for specific
causes are suggested in Tables 3
through 6. In addition, patients
should be instructed to maintain good
nail care, including rehydration, and
DERMATOLOGY NURSING/February 2003/Vol. 15/No. 1
Lunula
Epidermis
Matrix
Nail Plate
Cul-de-sac
(Proximal matrix) \ Cuticle
Nail Bed
to avoid occupational or environmental exposures. Good nail care is
important regardless of the cause of
the brittle nails and includes (Scher &
Bodian, 1991):
• Avoid using the nails as tools (for
example, scraper or screwdriver).
• Trim regularly to decrease likelihood of direct trauma (preferably
after bathing, when nails are fully
hydrated and soft).
• File after trimming to keep nail
edges smooth.
Gently buff nails to keep surfaces
smooth.
Again, caution the patient to
eliminate precipitating factors or
habits such as the use of dehydrating
21
soap^. solvents, and disinfectants;
scrubbing of the skin; and nail biting.
When exposure cannot be avoided,
encourage the patients to use protective measures such as thin cotton
gloves covered by rubber gloves to
guard against exposure to chemicals
and harsh detergents (Scher &
Bodian, 1991; Tosti & Piraccini,
2000). Although it is impossible to
avoid contact with water, patients
should be encouraged to lubricate
their nails and periungal skin several
times a day and after each exposure
to water. When cosmetic nail polishes
and adhesives have already produced
direct physical injury to the nail,
encourage the patient to avoid them.
Instruct patients on how to
hydrate their nails properly. The routine begins with soaking the nails for
15 to 20 minutes in lukewarm water
before bedtime. After soaking, apply
moisturizer directly to the nail unit
and cover the hands with white cotton gloves. This localized therapy
focuses on the exterior of the nail unit
— cuticle, plate, and folds — and is
very effective in treating the symptoms of brittle and splitting nails. Nail
care and rehydration should also
include the toenails to help reduce the
incidence of toenail problems that
can lead to discomfort in walking or
even chronic foot pain. Patients
should wear proper footwear and
rotate and replace shoes often.
The nurse should follow up regularly to provide support and determine if the patient is comfortable
with the treatment plan and
progress. Remember to explain that
the fingernails grow only about 3
mm each month and that it may take
5 to 6 months to see any significant
improvements (Tosti & Piraccini,
2000).
If preliminary measures of good
nail care and rehydration are unsuccessful, applying nail enamel without
formaldehyde and toluene may help
to improve the nails. Make sure the
patient understands that the enamel
should not be removed and reapplied
22
more than once weekly (Cohen &
Scher, 1992; Silver & Chiego, 1940).
To strengthen the nail and reverse the
brittleness and splitting, certain vitamins may be useful. Note, however,
that studies of gelatin, iron, and zinc
supplementation have not been
proven to increase nail strength, nor
has calcium supplementation demonstrated any benefit to strength or
shape of nails (Reid, 2000). The
exception is patients with documented iron or zinc deficiency, who may
benefit from taking those minerals.
Recent nail research has, however, targeted one supplement, biotin,
as useful. Investigators have documented that systemic treatment with
biotin 2.5 mg/d for at least 6 months
results in significant improvement in
nail quality (Colombo, Gerber,
Bronhofer, & Floersheim, 1990;
Gehring, 1996).
Biotin Treatment
What is //.^Biotin is a water-soluble vitamin component of the B complex. It acts as a co-enzyme for the
body's carboxylation reactions and is
a factor in maintaining healthy muscle, hair, and skin (Marcus &
Coulston, 2001; Stipanuk, 2000).
Several studies have supported the
success of biotin supplements in treating brittle nails (Columbo et al., 1990;
Gehring, 1996; Hochman, Scher, &
Meyerson, 1993).
Biotin is obtained naturally by
the ingestion of organ meats, egg
yolk, milk, fish, nuts, and whole grain
cereals (Marcus & Coulston, 2001;
Stipanuk, 2000). Biotin deficiency is
rare but may occur when patients fail
to consume or absorb adequate quantities of biotin-containing foods. The
deficiency occurs most often in
patients who have absorption disorders or who take medications that
alter the normal intestinal fiora, such
as oral sulfonamides, antibiotics, or
anticonvulsant agents (Marcus &
Coulston, 2001; Mock & Dyken,
1997; Mock, Mock, Nelson, &
Lombard, 1997). Symptoms of a
biotin deficiency include exfoliative
dermatitis, muscle pain, hyperesthesia, ECG changes, anorexia, anemia,
glossitis, weariness, and/or alopecia.
Even though brittle nails are
almost never associated with an outright biotin deficiency, several studies
have demonstrated that nails are
strengthened and their quality
improved when patients take 2.5
mg/day of oral biotin over several
months (Colombo et al., 1990;
Floersheim, 1989; Gehring, 1996;
Hochman et al., 1993). Biotin's mechanism of action is not yet known, but
one factor may be the vitamin's putative role as a stimulant of keratinization, which may affect nail health and
strength (Gehring, 1996; Schmidt,
1993).
Oral supplements of biotin are
more than 99% absorbed (Mock &
Malik, 1992; Zempleni & Mock,
1999). Once absorbed, 80% is free,
with the remaining 20^/() bound to
plasma proteins. Biotin appears to be
well tolerated, with no toxic side
effects reported even at higher doses
(Marcus & Coulston, 2001). The few
adverse effects, which are very rare
and relatively mild, include allergic
skin reactions and gastrointestinal
upset (Appearex Product Monograph, 2002; Hochman et al., 1993).
All of these factors make a once-a-day
dose of 2.5 mg of biotin a reasonable
recommendation for patients who
have not adequately responded to
other measures. Since this is a megadose of this vitamin, however, dermatologist supervision is indicated.
Clinical studies. For decades biotin
has been known to improve hardiness
and strength in the hoofs of animals.
Two studies have documented that
effect in horses and pigs (Comben,
Clark, & Sutherland, 1984; Webb,
Penny, & Johnston, 1984). Because
human nails are, like hoofs, made of
keratin, investigators have begun to
evaluate the use of biotin in humans as
a possible aid in nail health. Both
Floersheim (1989) and Colombo et al.
(1990) completed open-label studies
DERMATOLOGY NURSING/February 2003/Vol. 15/No. 1
1
s
of the vitamin and concluded that
biotin was an effective therapy for
humans with brittle nails. Further positive results were demonstrated in two
separate studies in 1993 by Hochman
et al. and Schmidt. Even more recently, a double-blind, placebo-controlled
study conducted by Gehring (1996)
documented statistically significant
improvement in nail quality, as measured by nail swelling and clinical
observation, in biotin-treated patients
compared with patients receiving
placebo. All published studies to date,
in fact, support the use of 2.5 mg/day
of biotin for brittle nails. The most significant points from these studies are
that biotin:
Strengthens nails and improves
nail quality.
Is nearly 100% absorbed when
taken orally.
• Is well tolerated with only very
rare gastrointestinal upset or
allergic skin reactions.
Results in noticeable nail
improvement within 3 to 6
months.
Summary
Nail problems can offer nurses
and other health care professionals
clues to a wide variety of dermatologic and other conditions and disorders.
Brittle nails can sometimes be considered a cosmetic problem but can also
adversely affect hand, finger, and toe
function. Even when only cosmetic,
that disorder can have significant
impact on a patient's quality of life
and self-esteem. Dermatology nurses
are in a unique position to collaborate
with the dermatologist to identify the
cause of a nail disorder and to establish an effective plan of care. Their
educational and emotional support
can enhance patients' adherence to a
treatment regimen, as well as help
them improve nail hydration and
care. Once systemic disease treatment has been maximized, the nurse
can take a primary role in educating
patients on proper nail care, hydration of nails, and the indication, safe-
Ombird, & A.G. Gilman (Eds.), Goodman
and Gilman's the pharmacologic basis of therapeutics (10th ed.) (pp. 1762-1763). New
York: McGraw Hill.
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