Women and men today value healthy, wellgroomed

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1 Nail cosmetics are big business in the US. A specialist highlights some benefits of nail cosmetics and offers tips to protect your patients from potential dangers. By Phoebe Rich, MD 38 Practical Dermatology October 2007

2 Women and men today value healthy, wellgroomed nails. The appearance of the nails may reflect overall health and good hygiene. For women, adornment of the nails may reflect a desire to accessorize or cosmetically enhance the appearance the nails, whimsy, and/or artistic expression. Salon-applied nail enhancements can even help to camouflage surface irregularities, such as pitting, or dystrophic nails resulting from dermatologic diseases like psoriasis. The range of options for nail adornment is wide, ranging from the simple application of polishes and lacquers to the use of acrylic nail extensions to application of screen prints, jewelry, and more. There s no doubt the cosmetic nail industry is large and growing. In 2005, Americans spent $6.84 billion on salon services alone. This figure does not include spending on nail care products and cosmetics from other sources, such as pharmacies and other retailers. Across the US, there are nearly 400,000 licensed nail technicians at 54,000 salons. By contrast, dermatologists number around 12,000. Although there has been some widespread attention paid to the issue of salon hygiene, the reality is that nail salons and nail enhancements are not necessarily inherently dangerous. Millions of women use nail cosmetics with no complications. Nonetheless, by nature of the sheer volume of patients who frequent nail salons, dermatologists are likely to encounter patients who have experienced a negative outcome associated with a nail salon service. The majority of these problems will be linked either to the materials used or to the mechanical procedures performed at salons. As dermatologists, we must be prepared to effectively identify and treat potential nail problems and educate patients so that they can safely pursue nail salon services. Reactions to Materials Allergic reactions. Allergic reactions associated with nail cosmetics are nothing new. In fact, the industry continues its efforts to minimize the use of some common allergens and irritants. Acrylates, of which there are multiple types, can be allergenic. Formaldehyde resin is one of the most common allergens associated with nail cosmetics. Although it is no longer used in overthe-counter nail products, it can be found in some salon products. Formaldehyde can still be found in some nail cosmetics. According to FDA regulations, formaldehyde may be present in nail cosmetics and hardeners in concentrations below three percent, and such products should not be intended to touch the skin. However, these federal guidelines apply to products traded across state lines, so it is possible for an in-state manufacturer to produce and locally distribute formulations that contain higher concentrations of formaldehyde. This is the case in my home state of Oregon, where I have seen patients react to a local product that contains formaldehyde. Although formaldehyde hardens the nails, it also makes them brittle, which is not desirable. Therefore, patients should avoid formaldehyde-containing products. Benzophenone is another allergen commonly found in nail cosmetics. Nickel beads used in nail lacquers have largely been replaced with polyester beads that are non-allergenic, however, the metal is still sometimes used. The clinical presentation of a reaction can help determine the source of the allergen, based on the chemistry of the material used. Allergic contact dermatitis to acrylics usually presents in a periungual distribution with a hyperkeratotic or even vesicular-type reaction. Patients complain of pain, itching, and burning, usually immediately after the nail procedure. Because acrylics polymerize very quickly, there is little opportunity for transfer of the chemical, and the reaction is limited to the area adjacent to the application site. By contrast, nail lacquer or polish hardens via evaporation rather than polymerization. Although a degree of hardening happens very rapidly, full hardening occurs slowly over time. The offending chemicals can be spread elsewhere on the body, including the neck and face. Eyelid involvement is very common, often in a focal distribution, though it may be diffuse. Polyester resins have replaced tosyl formaldehyde resin resin in over-the-counter and most salon products, but it may be found in some products. Patch testing easily and effectively identifies allergy to tosyl formaldehyde, and a simple use test can be performed. Much development in the nail cosmetics industry comes from advancements in the plastics industry, and new acrylates continue to emerge. To efficiently screen for acrylate allergies, test with ethyl methacrylate, which cross-reacts most other acrylates, obviating the need to individually patch test for each form. Methyl methacrylate is highly allergenic and has been banned by most states but may be used in products in some discount salons because it is rather inexpensive. It is more durable than ethyl methacrylate, which replaced it and is generally considered safer. Irritant reactions. Water is a significant irritant, and soaking of the nails during a manicure can be problematic. Reaction to nail polish remover is probably the most commonly seen irritant contact reaction. Acetate has largely replaced acetone as the primary ingredient in nail polish removers, but it is only slightly less dehydrating. Contact irritants can produce various clinical presentations, the most common of which are paronychia, onycholysis, and brittle nails. Paronychia results from a cycle initiated by loss of the cuticle as a result of the irritant reaction. Absence of the cuticle permits moisture, yeast, and bacteria to enter the nail fold, leading to inflammation and paronychia. Onycholysis may result from irritation caused by water or nail polish remover. October 2007 Practical Dermatology 39

Nail Cosmetics Onychoschizia peeling and brittleness at the nail tip is most common in individuals who frequently remove nail polish.

Note that nail yellowness among women who frequently paint their nails likely results from staining or discoloration produced by nail enamel dyes.

These granulations are not fungal and are thought to be produced by the base coat, though this is not proven. Nail Trauma Many cases of nail trauma result from procedures performed in the nail salon.

Electric dremel drills are used to file thick acrylic nails and to shape or file natural and artificial nails.

3 Nail Cosmetics Onychoschizia peeling and brittleness at the nail tip is most common in individuals who frequently remove nail polish. Some women change polish several times weekly to match outfits or simply on a whim. However, we recommend that patients remove polish only one time weekly. Note that nail yellowness among women who frequently paint their nails likely results from staining or discoloration produced by nail enamel dyes. Keratin granulations may also occur in patients who remove nail polish frequently as well as in individuals who leave pedicures in place for prolonged periods of time (three months is common). These granulations are not fungal and are thought to be produced by the base coat, though this is not proven. Nail Trauma Many cases of nail trauma result from procedures performed in the nail salon. Mechanical problems may result in onycholysis and paronychia. The most common cause of trauma is use of sharp instruments, such as clippers, metal cuticle pushers, and electric drills. Electric dremel drills are used to file thick acrylic nails and to shape or file natural and artificial nails. If the drill slips, it can cause damage to the nail and/or trauma and cuts to the skin that may lead to infection. Furthermore, the drill tips may not be sanitized or changed regularly and may be used from client-to-client, introducing the possible spread of infection. Home drill kits are also available. While these personal use devices limit the threat of infection spread, their use can cause damage in and around the nail unit. Clipping of the cuticles or manipulation with sharp metal cuticle pushers can damage the cuticle, decreasing defense against infection. A poorly sanitized clipper may even introduce infection. We advise patients to never clip their cuticles. Long natural or artificial nails can act as a lever that lifts the nail plate whenever pressure is applied to the nail tip. Constant use of the hands typing, opening cabinets, etc. produces chronic minor trauma that can lead to onycholysis and splinter hemorrhages among other issues. The nail plate naturally is attached tightly to the nail bed but loosely over the matrix. For this reason, when performing a nail Allergic contact dermatitis (top, left). Atypical mycobacterium as seen in patients after pedicures given in contaminated water (top, right). Brittle nails/onychoschizia (bottom, left). Keratin granulomas (bottom, right). avulsion, you will feel some give when you hit the matrix. When pressure is applied to long artificial nails, which are harder than natural nails, the nail will not bend or fracture. Instead, the nail will act as a lever and pull away from that loosely adhered nail matrix. A natural nail, by contrast, is much more flexible, and would quickly bend or fracture under pressure. Mechanical problems can lead to infection, bacterial, fungal (primarily dermatophyte and yeast), or viral. Infections can be spread from client-to-client in the salon when tools are not sanitized. A case of fatal MRSA following a pedicure has been documented. This specific case involved a paraplegic woman. The general recommendation is that paraplegics and diabetics avoid pedicures, since they may not detect cuts and nicks that may lead to serious infection. Such extreme cases are thankfully rare, but infections can occur with some frequency. When patients present with paronychia, attempt to culture pus from the area in order to make a specific bacterial diagnosis and institute appropriate antibiotic therapy. Dark nails associated with onycholysis are usually associated with pseudomonas, though there may be other causes. There is potential viral spread by incompletely sterilized pedicure implements. Paring of a wart that is misdiagnosed by the patient or salon technician as a callous, for example, can lead to viral spread for the individual and among clients. Herpetic whitlow may be associated with nail services. Pedicure procedures may present a unique opportunity for infection. In one case, roughly 100 clients at one salon expe- 40 Practical Dermatology October 2007

4 rienced boils and furuncles of the legs as a result of a microbacterium. The women had shaved their legs prior to using a footbath a common element of pedicures. Evidently, the water was contaminated, and it infected the women. Footbaths circulate water through a filter intended to collect debris. If the filter is not properly cleaned, debris caught in it can serve as a reservoir for infectious agents, even if the water is drained and replaced with fresh water for each client. Guidelines state that footbaths should be run with a bleach solution for at least 15 minutes between clients, but this is not often the case at busy salons. Another Risk There is some controversy regarding nail cosmetics in the healthcare setting. Some medical practices ban artificial nails for staff. Many hospitals and operating room nurse associations have either banned artificial or long natural nails or at least recommend against them. The threat posed by artificial nails in the healthcare setting is unproven, but there is cause for concern. Three patients developed Candida osteomyelitus following surgery that traced back to a scrub nurse. At a neonatal intensive care unit in Oklahoma, 46 cases of psuedomonas infections (15 of the babies died) were linked to two nurses. One of the nurses had artificial nails, and the other had long natural nails. New Developments A growing trend in nail cosmetics is the incorporation of sunscreens to protect the manicure from discoloration. Patients may believe the sunscreen is intended to protect the nail and may question whether they should be applying sunscreen to the nails. Advise patients that this is not necessary. The market for antimicrobial products distributed by nail salons also appears to be growing. Several topical anti-fungal products are sold for treatment or prevention of onychomycosis, and some products target bacteria. Data on these products are limited, but patients should recognize that onychomycosis or acute paronychia require medical attention and probably prescription medication. Tea tree oil is one ingredient that is particularly popular as an antimicrobial agent. While it does demonstrate some beneficial antimicrobial effects, it is also a potential allergen. Question

5 Nail Cosmetics Nail Tips (See text for full discussion.) Allergic contact dermatitis to acrylics usually presents in a periungual distribution with a hyperkeratotic or even vesiculartype reaction. Nail lacquer or polish hardens via evaporation; full hardening occurs slowly over time. Offending chemicals can be spread elsewhere on the body, including the neck and face. Eyelid involvement is common. Federal guidelines limit formaldehyde concentrations in nail products to 3%, but an in-state manufacturer may produce and locally distribute formulations containing high concentrations. To efficiently screen for acrylate allergies, test with ethyl methacrylate, which cross-reacts most other acrylates. Reaction to nail polish remover is a common irritant contact reaction. Patients should remove polish one time per week. Advise patients to never clip their cuticles. Damage to the cuticle decreases defense against infection. When patients present with paronychia, attempt to culture pus from the area in order to make a specific bacterial diagnosis and institute appropriate antibiotic therapy. Dark nails associated with onycholysis are usually associated with pseudomonas, though there may be other causes. Paraplegics and diabetics should avoid pedicures; they may not detect cuts and nicks that may lead to serious infection. patients about product use, including tea tree oil, when the source of allergic contact reaction is not immediately evident. It is worth noting that the popularity of pedicures is growing, and toenail care is becoming more complex. Increasing amounts of patients apply acrylic nails to the toes now. Safety Education Salons overall seek to provide safe and hygienic services to patients in order to attract and retain clients and avoid poor outcomes and their repercussions. The industry is making efforts at self-policing. The Nail Manufacturers Council (now part of the Professional Beauty Association) published salon regulations to help ensure safety and is involved in ongoing education programs, including a magazine for technicians. Some salons are still potentially problematic. These tend to be discount salons that offer cut-rate services. Encourage patients to avoid any such salons. Despite industry-wide efforts, state board regulation and licensing issues are inconsistent. There are no national standards for accreditation of technicians. Some states require just four weeks of training, while others require 18 months. Continuing education is not standard, either. There are typically too few inspectors to adequately police all salons. We as dermatologists can take an active role in educating local salon technicians about the importance of safe and hygienic practices. Basic education about nail health and possible signs and symptoms of nail disease could also prove beneficial. In some cases, the technician may be the only person beside the patient who ever sees the naked nail. If technicians could alert a client to potential problems, including possible cancers, the individual could seek full evaluation by a dermatologist. We must also emphasize education of patients, particularly those who visit nail salons: Above all, encourage patients to use only reputable salons. As a general rule, if the salon seems dirty or sub-par, it probably is. Instruct patients to use only licensed technicians and salons. They should physically view licenses, which should be on display. Patients should question the salon about its sanitation practices. Some salons employ hospital level sterilization procedures and have on-site autoclaves, and patients can trust such measures. If hospital-level sterilization is not enforced or clients are skeptical, advise patients to purchase and bring to each salon visit their own tools and implements. These are available at a pharmacy or beauty supply store. Some salons even sell or distribute tool packs to patients. All patients should also purchase their own manicure or pedicure packs containing items like pumice stones, files, and foam toe separators, etc. that cannot withstand sterilization procedures. Though not proven, I suspect that foam toe separators could be a significant source of infection transfer. Patients should never allow their cuticles to be cut. If pain, itching, or stinging develop, go to a dermatologist for evaluation. These symptoms may even develop during salon services. Immediately stop and seek dermatologic care. To minimize infection risk, particularly for those in healthcare, keep artificial or natural nails short. Patients should not shave their legs within 24 hours of a pedicure to reduce risk of infection from pedicure spas. The Dermatologist s Role Nail adornment is popular today, and a majority of our patients are probably visiting salons for services at least on an occasional basis. As dermatologists, our primary function is to help patients evaluate sources for nail care and identify safe alternatives if and when reactions occur. We may even recommend nail cosmetics to patients to camouflage dystrophic nails, nail pitting, and other surface irregularities resulting from conditions like psoriasis. Finally, we can help protect patients by being a resource for local technicians, sharing advice about safe, hygienic techniques and helping to increase the level of salon safety. October 2007 Practical Dermatology 43

Nail Fungus Guide Symptoms, Treatment and Prevention

Nail Fungus Guide Symptoms, Treatment and Prevention Introduction An infection of nail fungus occurs when fungi infect one or more of your nails. A nail fungal infection may begin as a white or yellow