Dystrophic nails run the gamut from minor to severe, with a host of potential causes, ranging from relatively benign to potentially significant. For many patients, nail abnormalities are not a cause of major concern, yet these individuals desire a diagnosis and guidance on how to restore nail health. According to Risha Bellomo, MPAS, PA-C, patients often treat nail disorders as a “by the way” concern mentioned at the end of an office visit, but clinicians can give nail complaints full attention and increase patient satisfaction.

WHY DO YOU THINK PATIENTS AND PROVIDERS MAY MINIMIZE NAIL DISORDERS?

“I believe a lot of patients mention their nail disorder because they do not like the way they look. They are looking for ways to improve their nails and need education on what is normal and what is not normal,” observes Ms. Bellomo. “Most providers just skim over this and it becomes a quick few word conversation. My opinion is we need to spend a little more time. If the provider does not have enough time at that visit because the patient mentioned it on the way out, then they should offer to bring the patient back in to discuss it further.”

WHAT ARE COMMON NAIL CARE MISTAKES PATIENTS NEED TO AVOID?

“Most OTC nail hardeners have formaldehyde or acrylics, which are bad for the nail,” Ms. Bellomo notes, so patients need to avoid these. If an underlying cause of dystrophy is found, it should be treated medically. For patients who want to improve nail cosmesis, prescription poly-ureaurethane, 16% (NuVail, Innocutis) can be effective. “Having an option like NuVail has been refreshing,” Ms. Bellomo says, “even though for some patients it is hard to obtain.” An effective and less expensive OTC option for nail fortification would be welcome, she says.

ARE THERE ANY STANDARD EVALUATIONS YOU DO FOR DYSTROPHIC NAILS? WHAT STRATEGIES DO YOU RECOMMEND TO PROTECT THE NAILS?

Ms. Bellomo says she always looks at the patient's nails when they bring it up, and usually asks them to return for a full evaluation. “I do at least a nail clipping, KOH and some time a scraping of the nail bed to send off for biopsy, especially if I am suspicious of onychomycosis or I am trying to rule out an underlying infection versus nail psoriasis or lichen planus,” she says. “I will also look for cutaneous manifestations.”

Poor nail quality can be associated with systemic diseases. “I do speak to them about comorbidities, such as diabetes and vascular disease, for example,” Ms. Bellomo says. “Also we will have a discussion of habits, hobbies, and occupation. I focus on avoiding bad habits, such as not using their nails as tools, avoiding excessive picking, pushing back their cuticles, and decreasing overexposure to water and chemicals. I do not recommend any products with formaldehyde, acrylics, or acetone.”