Nail problems are challenging, since the nonliving nail cannot be healed and can only be replaced by new growth. This new growth occurs slowly, requiring 6 months or longer for a new fingernail to be produced. Brittle nails that break very easily are a common problem. Water is the plasticizer of both the nails and the skin. Dehydrated nails become brittle and break.
At 30% water content, the nails are over hydrated and soft. The optimal water content for the nails is 16%, but this varies with humidity. Under conditions of 20% relative humidity, the water content of the nails drops to 7%. Proper hydration is key, however, as water allows the nails to bend without fracturing. Problems arise when the water is lost, since it is not possible to permanently replace the water. Nail soaking results in enhanced water loss and is not good for healthy nails.
The best treatment for brittle nails is prevention of damage to the newly growing nail plate. Nails become dehydrated with exposure to soap and solvents. When the hands are washed, so are the nails. Once piece of advice is to wash your hands, but avoid placing lots of soap on the nails unless they require cleansing. Hand sanitizers, which are replacing hand washing, are very damaging to the nails. The combination of the rapidly evaporating alcohol causes water loss. All soaps and household cleansers cause nail water loss making glove protection of the nails essential.
Many cosmetic products are available to strengthen nails. The common products are nail hardeners that contain formaldehyde. Formaldehyde works to harden nails by cross-linking the keratin protein. While this cross-linking makes the nail protein harder, it can also paradoxically make the nails more brittle. Thus, nail hardeners are not a recommended for strengthening brittle nails.
Perhaps the best way to strengthen brittle nails is with nail polish. Nail polish places a protective film over the nail. The flexible nail polish polymer increases nail flexibility and acts as a barrier to nail water contact. Problems arise, however, when the nail polish must be removed. Both acetone-containing and acetone-free nail polish removers dehydrate he nail. Thus, nail polish can be used in the treatment of brittle nails, but should be removed as infrequently as possible.
Some people also recommend the use of artificial nails in brittle nail treatment. While it is true that artificial nails can protect the underlying natural nail, removal of the artificial nail is always traumatic. With prolonged wearing, oxygen transport is decreased and the nail weakens. While artificial nails can be worn for a limited time, continued use for the treatment of brittle nails is not recommended.
Some also believe that brittle nails can be improved through diet. Nails are pure protein, thus adequate protein intake is necessary for healthy nails. Many strict vegetarians find their nails are one of the first places to show the effects of eating too little protein. Biotin has also been implicated as necessary for healthy nails. Egg whites are the richest source of biotin and many individuals do not consume eggs. Nutritionists also believe that biotin absorption across the small intestine decreases with advancing age. This is the rationale for biotin supplementation as part of nail health in mature individuals.
The use of biotin in human nails was adapted from the veterinary use of biotin in racehorses. If the hoof of a racehorse splits, it ends the career of the animal. Veterinarians supplement horse diets with biotin believing that it prevents hoof cracking. Whether biotin is useful in humans to prevent nail splitting has not been proven.
Perhaps the best way to treat dehydrated brittle nails is with a moisturizer. Two ingredients work best: urea and lactic acid. Both urea and lactic acid are classified as humectants because they increase the water holding capacity of the nail. This occurs from digestion of nail protein that opens up water binding sites and increases water content. The increased water content is only temporary, however, requiring continued moisturizer application.
Nail problems are common, yet difficult to treat. Nails are difficult to treat, as many times the condition requires new nail growth for resolution, which is time consuming. Since nails are nonliving, new growth is the only treatment option for many problems, yet the patient must be informed as to which activities should be avoided to prevent continuation of the problem. This article deals with a variety of nail conditions and presents treatment options for consideration.
Brittle nails are the most common cosmetic nail condition I encounter in my practice. There are many reasons nails may be brittle, but they all relate to the absence of water in the nail plate. Water is the plasticizer of the body allowing tissues to be flexible. Since the hands are washed frequently, so are the nails. While the living skin can be remoisturized with water drawn to the stratum corneum from the dermis and trapped by oily substances, this is not the case with the nonliving nails. Once the nail plate is dehydrated, the water can never be fully replaced. Thus, I stress to my patients that it is not necessary to vigorously wash the nails, if they are not dirty.
One of the most common newer causes of nail plate dehydration stems from the popularity of waterless hand sanitizers. These products contain triclosan, an antibacterial agent, in a rapidly evaporating vehicle. The vehicle efficiently removes water from the nail plate to a greater degree than traditional soap and water. For this reason, I advise my patients to avoid these hand sanitizers if brittle nails are a problem.
Nails are also dehydrated by the use of cleaning fluids that contain ammonia, bleach, and strong detergents. Contact with these substances may be necessary, but gloves should be worn to protect the nails from dehydration. It is worthwhile reminding the patient that only one contact with strong surfactants is necessary for dehydration to occur. Thus, consistency in hand protection is important.
Another common cosmetic nail problem is a broken nail where the break occurs proximal to the nail free edge resulting in removal of the nail from the nail bed. This type of broken nail is painful and a site of injury for infection. While the medical solution to this problem is new nail growth, a cosmetic repair can be helpful in alleviating pain and preventing infection. This technique utilizes a tea bag and clear nail polish. The tea bag is cut and the tea leaves emptied to obtain the surrounding fibered paper. A small piece of fibered paper is cut to fit over the nail break and an additional 2mm around the break. The broken nail is pushed back into place and covered with a layer of clear nail polish. The fibered paper is placed on the break and embedded in the clear nail polish followed by 2-3 extra coats. This technique reinforces the break with fibered paper held in place by nail polish as a semipermanent band aid until healing can occur.
This repair can be repeated as the nail grows and repeated as necessary. It uses commonly found materials costing little. Most patients who experience this type of painful broken nail wear their nails too long. The easiest suggestion to remedy recurrent broken nails is to cut the nail such that the free edge cannot be visualized over the fingertip as viewed from the palm of the hand. While the patient may not take kindly to the suggestion that she wear shorter nails, this is the only clinically reproducible method for reducing broken nails.
Longitudinal nail ridging is common as the nail bed ages. To explain the condition to patients, I liken longitudinal nail ridging to gray hairs. The ridge represents a group of nail matrix cells that are no longer producing a quality smooth nail plate. Typically, the ridge is permanent, as more ridges appear with advancing age. Fortunately, the ridge is only on top of the nail plate and can be removed by sanding the nail plate.
The nail plate is best sanded with a series of three nail files. The first nail file is coarse and should sand the nail ridge until smooth. This is best determined by rubbing the treated nail with finger pad of the same nail from the opposite hand. Once the nail is smooth, it is then filed with a finer file to increase smoothness and finally filed to achieve a high shine. Usually, the three files are sold together for under $5 in the drug store and labeled as cleaning, conditioning, and shining files. Each time the nails are cut, the filing sequence must be repeated, as new nail growth will contain the longitudinal ridge.
If the patient does not wish to perform the filing at home, this sequential filing routine can be included as part a regular manicure. The technique can be used by both men and women to remove longitudinal ridges and restore a more youthful appearance to the nail plate.
Habit tic deformity of the nail is usually characterized by horizontal ridges down the nail center. It results from repeated picking trauma to the nail and is most common when the thumbnail is manipulated by the first fingernail of the same hand. In most patients, it is a subconscious behavior in individuals who like to keep their hands moving. It is hard habit to break. I have experienced some success by offering another object for manipulation, such as a smooth stone, a strand of beads, a piece of cloth, or compressible ball. The patient can select a comforting object to manipulate in their pocket, instead of nail picking. The ridges can be smoothed once the nail picking stops with the same sequential filing technique described for the longitudinal ridges.
The final common nail problem observed is an ingrown nail. Typically, the great toenail ingrows either due to trauma, ill-fitting shoes, or improper nail grooming. It is important to identify the cause of the ingrown nail to allowing healing to occur and prevent recurrence. I find that educating the patient on proper nail cutting is very helpful. Most people like to cut their toenails in a gentle arc with the longest part of the nail in the center of the toe, similar to the technique used for fingernail cutting. This grooming method causes trouble on the toenails, but not on the fingernails, because the feet are forced into rigid shoes compressing the toenail against the skin.
The best way to cut the toenails when they frequently ingrow and cause pain, sometimes accompanied by infection, is to cut the sides of the nail longer than the center. This arc is opposite to the arc created by the toe pad. When the nail is shorter is the center, and pressure is applied to the nail, the corners of the nail move out, instead of in toward the skin. This alternation in nail mechanics prevents the nail from ingrowing. It is also more difficult for the sides of the nail to ingrow when they are longer.
Once the nail has ingrown, the best way to encourage the nail to grow properly is to place a small ball of cotton under the nail that is entering the skin. The cotton will elevate the nail and allow it to grow beyond the surrounding edematous tissue. It is easiest for the dermatologist to insert the cotton in small amounts with a toothless Adson-Brown forcep, pushing as far under the nail as possible with minimal pain. If the cotton becomes dislodged, it can be replaced by the patient, who can participate in the process in the office.
This article has discussed the most common cosmetic nail problems. In many cases brittle nails can be minimized by avoiding waterless hand sanitizers while a broken nail can be semipermanently repaired with a tea bag and clear nail polish. The appearance of longitudinal ridging and habit tic deformity can be improved with sequential nail filing. Finally, an ingrown toenail can be helped with a cotton ball and prevented with proper nail grooming. While nail problems can be difficult to treat, some simple ideas may allow treatment with great ease.