Lichen planus is a chronic inflammatory disorder that may affect the skin, scalp, mucosa, and nails. Nail lichen planus (NLP) presents with longitudinal ridging and nail plate atrophy and splitting. With progressive disease, irreversible nail changes, including dorsal pterygium and anonychia ensue, make NLP a true nail emergency that requires prompt and aggressive treatment (Lipner, 2019). Diagnostic difficulties, prolonged periods without treatments, and high recurrence rates even with effective therapy contribute to the development of anonychia and pterygium in patients with NLP (Iorizzo et al., 2020). Tasks such as buttoning a shirt, picking up a coin, and manipulating fine tools become challenging, if not impossible, once the nail undergoes scarring or is permanently lost.
Therapeutic solution
A pistachio nut shell may be used as a nail substitute or aid for patients with NLP and dorsal pterygium or anonychia to regain function and perform everyday activities. We previously described the use of a guitar pick as a nail prosthetic for patients with NLP (Gupta and Lipner, 2020). However, pistachio shells are an even more accessible and economical tool that may be used for this purpose. The shell width (11.7–12.3 mm, dependent on water content) roughly approximates that of the nail plate of the second digit in both women (11.1 mm) and men (12.3 mm; Jung et al., 2015, Maghsoudi et al., 2010). Pistachio nut shells are also compact, inexpensive, globally accessible, and easily replaceable if lost or broken. At <$1 per ounce with approximately 50 nuts (100 shells) in 1 ounce, a shell could be used as a single-use disposable option. To view a demonstration of the technique, click the image below (online version only).
We recommend that patients with a peanut or tree nut allergy use the guitar pick prosthesis as an alternative to the pistachio nut shell to avoid risk of allergic or anaphylactic reactions. Artificial nails are another option and may allow patients to feel less self-conscious. However, artificial nails are relatively expensive and easily broken and thus serve better as esthetic rather than functional aids.
With end-stage disease, NLP management should focus on improving functionality. For patients with NLP who have difficulty performing necessary tasks, such as picking up coins or manipulating a soup can tab, the use of a pistachio nut shell may be life changing. Patients with anonychia of the first three digits on either hand would benefit greatly from this technique because these are the digits used most frequently for fine manipulation. Educating patients with NLP and end-stage disease about this practical tool may aid them in performing activities of daily living.
Conflicts of interest
None.
Funding
None.
Study approval
The author(s) confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijwd.2020.12.016.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
A 75-year-old female patient with nail lichen planus who did not receive diagnosis or treatment for 7 years since onset. She was unable to perform activities of daily life, such as picking up coins or a grocery list from a flat table. Using a pistachio shell allows her to manipulate these objects where her nails would have otherwise been used.
References
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Associated Data
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Supplementary Materials
A 75-year-old female patient with nail lichen planus who did not receive diagnosis or treatment for 7 years since onset. She was unable to perform activities of daily life, such as picking up coins or a grocery list from a flat table. Using a pistachio shell allows her to manipulate these objects where her nails would have otherwise been used.