Current Practices of Subspecialty Nail Clinics: Results of a Survey of the Members of the Council for Nail Disorders

Abstract

Introduction

Knowledge of the structure and function of existing nail clinics remains limited. Sharing this knowledge from nail experts who run these clinics can readily support newly trained nail clinicians in setting up their nail clinics.

Method

We surveyed members of the Council for Nail Disorders (CND) to learn about the structure and practices of their nail clinics. Of the practicing CND members in any membership class, we analyzed responses from those who have nail clinics.

Results

Of the 79 practicing CND members, 38 responded (48.1% response rate), of whom 25 (65.8%) had a nail clinic. Analysis of these 25 responses revealed that 52% of nail clinics were relatively new (operating <5 years). The majority (72%) were in academic settings. Medical trainees were being taught in 64% of clinics. Nail clinics were directed by either one (64%) or multiple clinicians. All experts reported using clinical photographs in their routine care for nail patients, and 96% used dermoscopy. Additionally, 96% performed punch and tangential shave biopsies, and 88% performed matrixectomy. Access to a pathologist(s) with nail expertise was available in 84% of clinics.

Conclusion

Our findings characterize the current practices of nail clinics directed by CND members, serving as a guide for clinicians looking to establish their own.

Introduction

Nail disorders represent a diverse spectrum of conditions and a subspecialty that is ever-expanding in its’ diagnostic and therapeutic approaches [1]. The degree to which the diagnosis and management of nail disorders are taught during medical and podiatry school and residency varies widely. For example, a recent study emphasized the regional disparities in dermatology training, with many geographical areas having limited subspecialty training opportunities [2]. It is not surprising then that many practicing clinicians express that they feel uncomfortable caring for patients with nail disorders [3].

Many interventions are underway to increase access to education on nail disorders. These efforts are being led by academic institutions and professional societies, primarily the Council for Nail Disorders (CND), the American Academy of Dermatology (AAD), and the American Podiatric Medicine Association (APMA). Utilizing the learnings from these educational efforts to improve the care of nail disorders in their communities, dermatologists and podiatrists may want to create a subspecialty nail clinic or structure their routine clinics to augment their care of patients with nail disorders. Subspecialty clinics are also a useful mechanism for consolidating care for the purposes of research, teaching, and cost-effectiveness in focusing specialized equipment at one instead of many clinics. In addition, creating a subspecialty nail clinic in which trainees learn hands-on approaches will help fill the knowledge and experience gaps in nail disorders that has been reported by residents [4].

However, there is a dearth of literature on how to start and maintain subspecialty clinics. To work to fill this knowledge gap, we surveyed CND members and analyzed responses from those who direct subspecialty nail clinics for information on the current structure and function of their practices. The aim of this paper was to detail the current practices of experts in nail disorders who manage nail clinics. This information can serve as a reference for dermatologists and podiatrists looking to establish their own specialized nail clinics or modify their existing clinics to better care for patients and educate trainees.

Methods

We created a 13-question questionnaire using SurveyMonkey (see online suppl. material at https://doi.org/10.1159/000543535) which was emailed to all 229 members of the CND. We excluded responses from trainees or industry members. Our analysis therefore included responses from practicing members in the USA (n = 75), all of whom were board-certified, and from international dermatologists (n = 4), resulting in a total number of 79 responses. We then analyzed the survey responses of those who reported having designated nail clinics (n = 25, Table 1). We also summarized the survey responses of those CND practicing members who reported not having a designated nail clinic (n = 13) and provided those for completeness (Table 2), though no attempt to compare the two groups was made as this was not an aim of the study.

Table 1.

CND practicing member survey results on structure and function of subspecialty nail clinics

	Providers running subspecialty nail clinics (N = 25), n (%)
Duration of nail clinic in years
<5	13 (52)
6–10	3 (12)
11–15	3 (12)
>15	6 (24)
Patients seen in nail clinic per week, n
<10	12 (48)
10–15	4 (16)
>15	9 (36)
Settings
Academic	18 (72)
Single-specialty private	9 (36)
Multispecialty nonacademic	3 (12)
Veterans’ administration clinic/hospital	3 (12)
Care delivery models
In-person	25 (100)
Telemedicine	9 (36)
E-consults	10 (40)
E-visits	5 (20)
Approximate wait time for new patients in weeks
<4	9 (36)
4–8	8 (32)
9–16	5 (20)
17–24	2 (8)
>24	1 (4)
Other nail experts or patients’ extenders in the nail clinic
0	16 (64)
1	5 (20)
2	3 (12)
>2	1 (4)
Trainees in the nail clinic
Yes	16 (64)
Usage of a triage system to determine appropriateness for nail clinic
Yes	9 (36)
Diagnostic tools
Dermoscopy/onychoscopy	24 (96)
Clinical photographs	25 (100)
KOH	19 (76)
Fungal culture	18 (72)
PAS	20 (80)
PCR	9 (36)
Dual-action nail nipper	23 (92)
15C blade	15 (60)
Nail template in cassette	15 (60)
Procedures performed in the nail clinic
Punch biopsy of nail unit	24 (96)
Tangential shave biopsy	24 (96)
En bloc excision of the nail unit	11 (44)
Matrixectomy (phenol/other method)	22 (88)
Myxoid cyst excision/destruction	14 (56)
Mohs micrographic surgery	5 (20)
Access to a pathologist(s) with expertise in nail pathology
Yes	21 (84)
Interest and skills in nail disorders developed
During residency in a program with nail clinic	4 (16)
During residency in a program without a nail clinic	10 (40)
After residency	13 (52)
Mentorship from a nail expert	18 (72)

Table 2.

Survey responses of CND practicing members who reported not having a dedicated nail clinic

	Providers without a dedicated nail clinic (N = 13), n (%)
Nail patients seen per week, n
<10	5 (38.5)
>15	1 (7.7)
Settings
Academic	6 (46.2)
Single-specialty private	6 (46.2)
Multispecialty nonacademic	1 (7.7)
Veterans’ administration clinic/hospital	1 (7.7)
Care delivery models
In-person	13 (100)
Telemedicine	1 (7.7)
Approximate wait time for new patients in weeks
<4	6 (46.2)
4–8	3 (23.1)
9–16	1 (7.7)
17–24	1 (7.7)
>24	1 (7.7)
Other nail experts or patients’ extenders
0	8 (61.5)
1	2 (15.4)
2	1 (7.7)
>2	1 (7.7)
Trainees
Yes	7 (53.8)
Usage of a triage system
Yes	3 (23.1)
Diagnostic tools
Dermoscopy/onychoscopy	11 (84.6)
Clinical photographs	10 (76.9)
KOH	6 (46.2)
Fungal culture	11 (84.6)
PAS	7 (53.8)
PCR	2 (15.4)
Dual-action nail nipper	6 (46.2)
15C blade	5 (38.5)
Nail template in cassette	3 (23.1)
Ropivacaine	2 (15.4)
Bupivacaine	1 (7.7)
Procedures
Punch biopsy of nail unit	9 (69.2)
Tangential shave biopsy	7 (53.8)
En bloc excision of the nail unit	2 (15.4)
Matrixectomy (phenol/other method)	7 (53.8)
Myxoid cyst excision/destruction	5 (38.5)
Mohs micrographic surgery	2 (15.4)
Access to a pathologist(s) with expertise in nail pathology
Yes	9 (69.2)
Interest and skills in nail disorders developed
During residency in a program without a nail clinic	3 (23.1)
After residency	8 (61.5)
Mentorship from a nail expert	4 (30.8)

Results

Of the 79 CND practicing members, 38 responded with a response rate of 48.1%. All results detailed in this manuscript are those of respondents who reported “yes” to question 1 of the survey, “Do you have a designated nail clinic in which you try to schedule most of your nail patients?” except for Table 2, which provides, in the interest of completeness, the results of respondents who answered “no” to question 1 of the survey.

Of those who responded to the survey, 25 (65.8%) reported having a designated nail clinic (Table 1). Of the 25 clinicians who have designated nail clinics, 52% (n = 13) have directed their clinics for less than 5 years, and 24% (n = 6) have directed theirs for more than 15 years. The majority (72%, n = 18) of nail clinics were based in an academic setting, and medical trainees were routinely taught in (64%, n = 16) of the clinics. The survey showed that the most used diagnostic tools were clinical photographs (100%, n = 25) (shown in Fig. 1), followed by dermoscopy/onychoscopy (96%, n = 24), dual-action nail nipper (92%, n = 23) (shown in Fig. 2), and PAS (80%, n = 20). The most frequently performed nail procedures included punch and tangential shave biopsies (96%, n = 24) and matrixectomy (88%, n = 22). Additionally, 20% (n = 5) of clinicians reported performing Mohs micrographic surgery. Access to a pathologist(s) with expertise in nail disorders was available in 84% (n = 21) of nail clinics.

Fig. 1.

Clinical photograph of a fingernail (status posttraumatic injury) demonstrating the optimal angles for clinical use in diagnosis and monitoring response to therapy: surface (a), free margin (b), and 2 lateral views (c, d).

Fig. 2.

Dual-action nail nipper.

We also surveyed CND members about methods by which they developed skills and experience in managing nail disorders. The majority of clinicians (72%, n = 18) reported they developed their interest and skills from mentorship by a nail expert. A minority (16%, n = 4) reported developing skills during residency in a subspecialty nail clinic within the residency program.

Discussion

Subspecialty clinics led by experts provide comprehensive medical care, advanced medical education, and more research opportunities [5]. These clinics are condition-based, which allow patients to benefit from specialist expertise and enable the introduction of new diagnostic, therapeutic, and surgical approaches.

We aimed to share the aggregate current preferred practices of nail experts as to the structure and function of subspecialty nail clinics to assist dermatologists and podiatrists who want to establish their nail clinics. Our survey results showed that 52% (n = 13) nail clinics were relatively new (duration less than 5 years) which supports our experience that more colleagues are reaching out for guidance for how to start a nail clinic. Our results show that nail clinics have successfully been established within a wide variety of practice settings, run by one or more clinicians, and deliver care via in-person and virtual models. We therefore hope that by utilizing the practices of experts as detailed here, clinicians will be empowered to start a nail clinic in any practice setting. A triage system utilizing an instrument such as a decision tree is an approach that assists schedulers with identifying patients in need of subspecialty care and that was reported as being used by 36% (n = 9) of those who direct nail clinics. One of the authors (M.A.H.) uses a triage system and finds it helpful for maintaining the subspecialty nature of the clinic (shown in Fig. 3).

Fig. 3.

Diagram of the triage system used in the University of Wisconsin Nail Disorders Clinic to decide appropriateness of cases for nail clinic.

In subspecialty nail clinic, nail experts reported utilizing a wide range of diagnostic and surgical skills and tools to optimize patient care. Clinical photographs, dermoscopy, and dual-action nail nipper were the most utilized tools for diagnosis. Punch biopsy, tangential shave biopsy, and matrixectomy were the most performed diagnostic and therapeutic techniques. Knowledge of the importance of these tools and skills to nail experts should inform those interested in creating a nail clinic that training is important to acquire before starting a nail clinic [6]. Access to a pathologist with nail expertise is an integrated component in most nail clinics (84%). This access is very important because of the critical nature of the clinical-pathologic correlation to the comprehensive, effective care of patients with nail disorders.

By publishing the findings of this survey of CND members, we hope to help emerging, newly initiated, and existing nail experts in directing their clinics with an understanding of how their peers who have established subspecialty nail clinics are currently practicing. Suggestions for future research include surveying members of other professional societies such as the AMPA.

Limitations

Limitations to our survey were that it only included CND members and no other professional society members. However, the CND includes members who are dermatologists and podiatrists as a sample of the specialists who primarily care for patients with nail disorders, and our data did not reveal significant discrepancies among the current practices of specialty nail clinics, indicating that our sample is likely representative of the current nail clinic practices.

Acknowledgments

We would like to thank all CND members who participated in our study.

Statement of Ethics

This study was approved under the exempt category by the Institutional Review Board at the University of Wisconsin-Madison. The need for informed consent was waived by the Institutional Review Board at the University of Wisconsin-Madison.

Conflict of Interest Statement

Dr. Molly A. Hinshaw is a co-founder of Accure Medical Inc. Dr. Phoebe Rich has no conflict of interest, and Safinaz Soliman, MBBCH, has no conflict of interest.

Funding Sources

This study was not supported by any sponsor or funder.

Author Contributions

All authors have contributed substantially to the production of this manuscript. S.S. drafted the manuscript and conducted data analysis for this project. P.R. contributed toward conceptualization, reviewing, and editing of the manuscript. M.A.H. led the conceptualization and administration of this project, drafted the survey, and led the reviewing and editing of the manuscript.

Funding Statement

This study was not supported by any sponsor or funder.

Data Availability Statement

Data generated or analyzed during the study were included in this article. Further inquiries can be directed to the corresponding author.