Onycholysis is the most common type of acquired onychodystrophy, characterized by a violation of the connection between the nail and the nail bed while preserving the matrix. Clinically manifested by the inability of the nail plate to grow to the nail bed when separating the nail from the distal edge. With non-infectious onycholysis, the nail plate does not change the consistency and color. With the defeat of the infectious genesis, the nail becomes cloudy, becomes rough. The disease is diagnosed clinically, scraping from the lesion to fungi is mandatory, the exclusion of somatic pathology is required. Treatment is long-term, includes rehabilitation of foci of chronic infection, vitamin therapy and the appointment of mineral-containing drugs.
General information
Onycholysis is a distal detachment of the nail plate from the bed. The pathological process occurs on one finger of the hands or feet or affects several fingers at once. In 60% of cases, onycholysis is a consequence of traumatic injury, in 30% it develops as a result of chronic dermatomycosis, the remaining 10% are systemic somatic diseases, dermatoses and pyoderma. Onycholysis can occur at any age, it is more often diagnosed in women, which is associated with professional nail care. It has no racial or seasonal differences, and is not endemic. The disease was first described by Geller in 1910. The relevance of the problem is determined by the aesthetic component, which negatively affects the quality of life of the patient.
Causes
The causes that caused onycholysis can be divided into three groups: trauma, mycosis and allergy. The mechanism of development of the pathological process varies depending on the etiology.
In case of injury, both the nail and the nail bed are involved in the pathological process. A hematoma is formed between them, mechanical compression of blood vessels occurs in the dermis, the nutrition of the nail is disrupted, its chemical composition and elasticity change. The nail is deformed. Due to the violation of the trophic collagen ligaments that fix the nail to the nail bed, the connection between the nail plate and the bed weakens, the nail moves away from the free edge. The larger the area of detachment, the higher the risk of secondary infection with the development of inflammation. At the same time, the connection of the nail with the matrix is not interrupted, therefore, after resorption of the hematoma and restoration of the trophic tissues, the nail begins to grow as before.
The basis of infectious onycholysis is inflammation, which goes through three stages: alteration, exudation, proliferation. In the first stage, pathological damage to the dermis occurs, the cells of the immune system and the reticuloendothelial system of the skin begin to produce cytokines and inflammatory mediators. The process of blood supply is disrupted, the trophism suffers, the structure of the nail changes. The stage of exudation aggravates all these disorders and entails a violation of the water-electrolyte balance.
The nail swells, becomes vulnerable to fungi and bacterial flora, which are embedded in the intercellular layers of the nail plate. The process of damage to the lower part of the nail and the nail bed begins, the nail plate separates from the bed. The more microbes are involved in the pathological process, the more intense the process of detachment. T-lymphocytes and phagocytes destroy foreign antigens, stimulating the process of proliferation – the final stage of inflammation, which leads to hyperkeratosis of the nail bed and its deformation. In parallel, hyperkeratotic growth of the nail plate begins, designed to restore the resulting defect. Normal nail growth is possible after complete relief of the inflammatory process.
Allergic onycholysis is similar to inflammatory, but at the stage of exudation, the reaction of excessive antibody production to microbes embedded in the dermis and nail prevails, which leads to hypersensitivity of the skin, aggravates the processes of deformation of the dermis and nail plate, slows down the regeneration processes.
Classification
To prescribe adequate therapy , taking into account the heterogeneity of pathology , several types of onycholysis are distinguished in dermatology:
- Traumatic – occurs as a result of damage to the nail or the sub-elbow space due to wounds, burns, splinters, chemical or physical influences, prolonged exposure to water or wearing tight shoes.
- Dermatological – is a consequence of long-term dermatoses with trophic disorders in the affected area.
- Endocrine – formed against the background of endocrine disorders and humoral disorders.
- Systemic – develops with systemic pathology of the digestive tract and metabolic disorders.
- Fungal – is the result of the formation of colonies of microbes in the subcutaneous space with changes in the nail bed while maintaining a normal nail. It can become the result of a long-existing mycotic infection with damage to the nail plate and the formation of foci of secondary onycholysis.
- Bacterial – occurs when a secondary infection is attached.
- Allergic – develops against the background of taking medications with photosensitizing properties, contact with chemicals, UVI.
Symptoms
The clinical picture of the disease is typical and is characterized by the separation of the nail plate from the nail bed from the free edge in the distal or lateral sections to the nail well. Visually, there is a change in the color of the nail from flesh to whitish-gray, which is due to the ingress of air into the sub-elbow gap. If microbes get there instead of air, the color of the nail changes. Bacteria cause the nail to turn yellow, mushrooms give a brownish tint, pseudomonas infection – greenish. With a microbial lesion, the consistency of the nail plate also changes, it becomes rough, begins to deform. Dirt and keratin accumulate in the space between the nail and the nail bed, and subcutaneous hyperkeratosis with an unpleasant odor is formed. The formation of foci of secondary onycholysis is possible. If only part of the nail peels off, partial onycholysis occurs, if the entire nail is total.
Diagnostics
Usually, the diagnosis does not cause difficulties for a dermatologist. The nail lesion preceding onycholysis with lines is a valuable diagnostic sign, indicating either permanent injury to the nail, or periodic cessation of its growth against the background of somatic diseases. The presence of a lesion on one or more fingernails or toenails and the determination of the possible cause of detachment make it possible to establish a clinical diagnosis with a significant variety of pathomorphological picture of onycholysis (change in color, structure, transparency, hyperkeratotic layers different in depth and area). It is mandatory to take a scrape on mushrooms to exclude mycotic lesions. Differentiate onycholysis with mycoses, Bowen’s disease, psoriasis, lichen planus and onychodystrophy of unclear etiology.
Onycholysis treatment
Therapy of the pathological process is complex. If possible, it is necessary to stop the underlying disease that caused onycholysis. With the development of medicinal onycholysis, it is recommended to correct the work of the digestive system with the help of a gastroenterologist, since nail detachment occurs as a result of a lack of minerals and vitamins, without which normal nail growth is impossible. In case of traumatic onycholysis with partial detachment of a small area of the nail, daily shearing of the detached area is carried out with disinfection and protection of the nail bed with an antibacterial patch.
A large area of detachment is treated surgically, bandages with antibacterial and antiseptic solutions are applied. During the operation, hyperkeratotic layers, hematomas and dirt are removed. The nail is restored with the help of prolonged use of gelatin solutions of various concentrations. In onycholysis of bacterial or mycotic nature, alcohol solutions of aniline paints, antibacterial and antimycotic drugs are additionally used. Patients with onycholysis are shown vitamins, iron and calcium preparations, general tonic agents. Contact with water, cosmetic lacquers and household chemicals is contraindicated. The prognosis is relatively favorable, taking into account possible cosmetic defects.