Onycholysis
Nails with onycholysis usually are smooth, firm, and without inflammatory reaction
Medical Care
Treatment for onycholysis varies and depends on its cause. Eliminating the predisposing cause of the onycholysis is the best treatment. Onycholysis related to psoriasis or eczema may respond to a midstrength topical corticosteroid. Pulsed dye laser treatment was reported as effective for psoriasis-induced onycholysis in one small series,11 but caution is advised until more data are available regarding this intervention. Psoralen plus ultraviolet A (PUVA) treatment has also been reported as an effective therapy for psoriatic onycholysis.12
* Patients should avoid trauma to the affected nail, and keep the nail bed dry.
* Patients should avoid exposure to contact irritants and moisture (important).
* Patients should clip the affected portion of the nail, and keep the nails short.
* Patients should wear light cotton gloves under vinyl gloves for wet work.
Intralesional injection may be required for onycholysis associated with more severe psoriatic nail dystrophy.
* Triamcinolone 2.5-5 mg/mL diluted with normal saline is injected into the proximal nail fold every 4 weeks in a series of 4-6 sessions.
* The proximal nail fold overlying the nail matrix is the ideal site for treatment of diseases that begin at the matrix (eg, psoriasis).
* A 30-gauge needle is adequate for medication delivery; a topical anesthetic may be used to reduce pain.
* Improvement should start after the initial series; continued injections depend on disease recurrence.
* For other nail changes associated with onycholysis (eg, oil drop sign of psoriasis, distal onycholysis, subungual hyperkeratosis), the ideal location for intralesional injection is the nail bed. The pain of this procedure necessitates the use of anesthesia. This problem can be overcome by injecting the lateral nail folds in an attempt to get medication to the affected area.
Activity
Advise patients with onycholysis to avoid contact irritants, trauma, and moisture.
Medication
In onycholysis, apply a topical antifungal imidazole or allylamine twice daily to avoid superinfection of the nail. An oral broad-spectrum antifungal agent (ie, fluconazole, itraconazole, terbinafine) may be used for cases with concomitant onychomycosis.
Midstrength topical corticosteroids are suitable for isolated onycholysis. High-potency topical steroids (eg, clobetasol ointment) under occlusion have been used with less than ideal results for patients with severe nail dystrophy unwilling to undergo intralesional injection of corticosteroids. Patients follow this regimen for 2 weeks and then discontinue use of topical steroids for 2 weeks to avoid the other local adverse effects of topical steroids.
Massaging 5-fluorouracil 1% solution twice a day into the proximal nail fold for 4 months has been effective for patients with nail pitting and hyperkeratosis from psoriasis. Application to the free end of the nail should be avoided, as this will cause onycholysis. Localized PUVA, oral etretinate, hydroxyurea, and isotretinoin are other agents that have had some success in treating onycholysis resulting from psoriasis.
Treatment is not without adverse effects. They may include subungual hematoma secondary to intralesional steroid injections and photo hemolysis secondary to PUVA treatment. Explain risks to patients before initiating therapy.
Antifungals
Treat superinfection of the onycholytic nail by dermatophytic molds and/or candidal yeasts.