Treatment of Nail Fold Hypertrophy by Combining Conservative Techniques

Abstract

Introduction

Hypertrophy of the nail folds is a common condition. It occurs by alteration of shape, partial loss, or absence of the nail, resulting in loss of the nail fold physiological limit. This can also occur by the friction of the nail with the nail fold. Consequently, there is an increase in the volume of the lateral or distal nail fold and a decrease in the space of the nail bed and the nail plate. Management of this onychodystrophy may be conservative or surgical.

Case Presentation

We present a case of distal nail embedding after trauma, submitted to conservative treatment. Combined techniques were required as trichloroacetic acid application, rolled cotton padding maneuver, artificial resin nail technique, and orthesis. After 14 months, good functional and aesthetic results were obtained, with correction of the anatomical shape of the nail unit.

Conclusion

The conservative techniques for hypertrophy of the nail folds are a useful option with good functional and aesthetic results. The indication must be precise, considering the history of the patient and after discarding bone alterations by image exams. The disadvantage of the method is the long treatment time and constant visits to the doctor's office.

Established Facts

• Hypertrophy of the nail folds is a common condition and can change the shape of the nail plate and cause local pain.

• The therapeutic proposal for hypertrophy of the nail folds is most often surgical.

Novel Insights

• Description of conservative treatment with associations of techniques.

• Option for patients when the surgical procedure is unwanted or contraindicated.

Introduction

Hypertrophy of the nail folds occurs more frequently in the hallux. It consists of increasing the soft tissue volume at the distal edge of the nail. This forms a wall that blocks the normal growth of the nail plate toward the free margin. The hypertrophic tissue is located at the front and a level above the nail plate. As a consequence, the nail plate can penetrate in the distal hypertrophic region, causing ingrown nail, or modifying its growth path up or to the 1 side. Thus, complications such as distal nail embedding, onycholysis, or phlogistic inflammatory signs occur if the nail bed has become short and the nail plate can advance over the hypertrophy [1, 2].

The main cause of hypertrophy of the nail folds is acquired, due to total or distal nail avulsion and inappropriate nail cutting. Another cause is the congenital origin, such as congenital anonychia or bad congenital alignment of the nail [1].

The pathophysiology is explained by understanding the function of the nail in the gait cycle. The nail plate in its normal position neutralizes forces that are exerted on folds of the nail during the propulsive movement. When walking, first occurs the support the heel on the floor, then the sole makes the complete contact to the floor, followed by propulsion in the forefoot for a new step. In the absence of the nail plate, no counterpressure occurs during the propulsive movement. This allows dorsal expansion of the plantar portion of the pulp and hyponychium [1, 2, 3, 4, 5].

We present a case of hypertrophy of the nail folds whose management was made through conservative combined techniques with good functional and aesthetic results.

Case Report

We present a case of a 34-year-old female patient with a history of nail trauma in the right hallux for 5 months, followed by complete onycholysis and loss of the nail plate. The new nail appeared slowly, allowing the lateral and distal folds to reposition. In clinical examination, she presented the nail with increased transverse curvature and upward directing, shortening of the nail bed, and hypertrophy of the nail folds (shown in Fig. 1, 2).

Fig. 1.

Hypertrophy of the nail folds. Nail plate with increased transverse curvature − dorsal image. Treatment proposal: use of 70% TCA in the hypertrophy lateral − distal edges (blue).

Fig. 2.

Hypertrophy of the nail folds. Nail plate with upward directing − lateral image. Treatment proposal: use of 70% TCA in the region distal to the nail bed (red).

Conservative treatment using multiple techniques was the option adopted. Initially, 70% trichloroacetic acid was applied monthly in the lateral-distal nail folds and in the region distal to the nail bed to reduce hypertrophy and lengthen the nail bed (shown in Fig. 1, 2).

Rolled cotton padding maneuver was executed to protect the lateral folds in contact with the nail (shown in Fig. 3). As the hypertrophy of the fold decreased and the nail bed advanced, other techniques were used as orthesis to flatten and correctly guide the nail plate (shown in Fig. 3). Artificial resin nail technique to define the nail territory was used as well.

Fig. 3.

Hypertrophy of the nail folds − rolled cotton padding maneuver and orthesis.

The patient presented good functional and aesthetic results after 14 months of conservative therapy (shown in Fig. 4, 5).

Fig. 4.

Hypertrophy of the nail folds − before treatment.

Fig. 5.

Hypertrophy of the nail folds − after treatment with good functional and aesthetic result after 14 months.

Discussion

In our literature review, we did not find publications with conservative treatment for hypertrophy of the nail folds. This asserted the relevance of the clinical case described with the therapeutic success of associated conservative techniques [6, 7].

Conservative treatment, which the main objective is to reduce the distal hypertrophic process in the distal nail embedding, has been proposed when the patient has little discomfort or is asymptomatic. When the conservative approach is insufficient or the patient presents severe pain, the surgical treatment becomes the appropriate choice. The goal is to decrease hypertrophy of the distal border, allowing continuous and physiological growth of the nail [2, 8].

Conservative management of hypertrophic tissue can be performed using 50% urea ointment or trichloroacetic acid, which was used in our patient. Trichloroacetic acid was used in the hypertrophic tissue and distal region of the nail bed. Treatment aims to decrease distal hypertrophy as well as decrease the thickness of the skin in front of the nail bed, thus increasing peripheral vascularization, lengthening the nail bed attaching it to the nail plate [2].

In the described case, apart from the mentioned alterations, the patient's nail presented changes resulting from hypertrophy of the nail folds: upward growth and an increased transverse curvature. A padding maneuver that has been used can be made with rubber, silicone, dental tape, or cotton; the latter was the material of choice. The rolled cotton padding maneuver was done until the nail was flat and covering the back of the finger to the distal region. The material of choice is located underneath the nail in the lateral and distal regions. A space of a few millimeters is formed, avoiding the penetration of the nail in the skin and containing the transverse curvature. This ensures the continued physiological growth of the nail [6].

In the case of increased transverse curvature of the nail, an orthesis was applied to flatten the nail plate. These devices, made of steel wire, rubber, or memory fiber, are applied at the nail's plate dorsal. The mechanism by which they achieve their goal is different. The steel wire is anchored under the 2 side edges of the nail and is adjusted gradually, just like the rubber. While the memory fibers are glued to the back of the nail, their effect will depend on the tension memory of the material [9].

Cases of distal nail embedding that present shortening of the nail bed consequently will have a shorter nail plate, as described. The artificial resin nail technique is used to sculpt a larger nail plate than the existing one. The purpose is to control and contain hypertrophy and define a pathway for the nail plate [7].

Memory fiber and artificial resin nail, as used in our case, were used at different times. The first step was flatting the nail plate using the memory fiber monthly for 8 months. When the nail plate was flat but still short, we used the resin to delimit the pathway of the nail plate.

An appropriate recommendation for the patient with hypertrophy of distal nail folds is to massage the dorsal portion of the distal fold into the distal-plantar direction, projecting to the opposite side of the hypertrophied portion, giving passage to nail plate [10].

The use of conservative techniques is a useful option with good functional and aesthetic results. The indication must be precise, considering the patient history and after exclusion of bone disorders by image exams. However, the disadvantages of this method are the length of the treatment and frequent visits to the doctor's office.

Statement of Ethics

All patients signed an informed consent allowing the publication of this information.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This article has no funding source.

Author Contributions

All authors contributed to the design, data acquirement, writing, and editing.