Ugly Risks of Beauty Routines

, University of Medicine & Dentistry of New Jersey


Medscape General Medicine. 1996;1(1) 

In This Article

Nail Infections

The woman with a chronic fungal infection of her nails may arrive in the clinician's office complaining that her nails have become thick and discolored, or that 1 or more nail plates have begun to detach from the underlying skin. A patient presenting with an acute bacterial infection may have erythema and tenderness around the nail margin and perhaps extending under the nail. Infections in or around the nail can be caused by bacterial, fungal, or viral organisms, typically introduced by contaminated equipment through skin breaks during a procedure. This can occur during home manicures/pedicures with equipment inadequately cleaned between uses as well as during professional manicures/pedicures where there is improper care of instruments between clients or where the operator is inexperienced. Most states now require licensure of nail salons and manicurists and have instituted specific guidelines, such as single-use instrument kits, in nail-care salons.

Because there can be bleeding or skin breakthrough of the tissue surrounding the nail during cuticle trimming or callus removal, the possibility exists for transmission of blood-borne pathogens from client to client with nonsterilized instruments. While in theory the pathogens transmitted could include HIV, in reality transmission of hepatitis B and C are more likely.[11] Although not usually fatal, these diseases can certainly cause significant morbidity and represent a public health hazard. In the case of hepatitis B in pregnancy, vertical transmission is possible.

Bacterial infections from the usual skin pathogens, namely Staphylococcus and Streptococcus, can also occur from skin and/or soft-tissue injury during a manicure or pedicure. These infections are usually self-limiting and require only local care, but in some cases, particularly in diabetic or immunocompromised patients, severe infections can result. The pyogenic bacteria, particularly some group A streptococcal infections (the "flesh-eating" bacteria), can cause more serious disease requiring intravenous antibiotic and surgical intervention.

The most common fungal nail infection, occurring in 15% to 20% of adults between the ages of 40 and 60, is onychomycosis, which can be caused by a variety of fungal agents. Onychomycosis (Fig. 3) occurs more often in older women, possibly because estrogen deficiency may increase the risk of infection[12]; furthermore, the higher incidence of diabetes and peripheral vascular disease in older women may also contribute to this increased risk. Women who have artificial nails--either acrylic or "wraps"--are particularly susceptible to onychomycosis. Before an artificial nail is applied, the surface of the nail is usually abraded with an emery board. This procedure damages the nail surface and creates a possible nidus of fungal infection. Additionally, an emery board used on a fungus-infected nail can introduce the fungal infection to an uninfected nail on the same person or to the next emery board user. Fungal infection can also occur when the woman has her nail tips or wraps in water and collects water in and under the nail. Under these circumstances, the moist, warm environment for fungal growth is established and the nail under the tip or wrap becomes infected.

Figure 3. The incidence of toenail infections is 4 times higher than that of fingernail infections.

Women should be instructed to clean their manicure/pedicure instruments between each use, replace emery boards frequently, avoid tips and wraps, push rather than cut the cuticle, use a clean pumice stone on calluses rather than cut them, and refrain from sharing their tools with others. If a fungal infection develops, instruments used on the infected nail should either be sterilized or not be used on uninfected nails.

It is imperative for women who use salons to ascertain licensure and staff credentials, avoid cuticle cutting, ask if multiple-use instruments have been sterilized (or take their own), and tell the manicurist to stop if a procedure causes pain or bleeding.

The incidence of toenail infections is 4 times higher than that of fingernail infections.[13] This finding may be attributable to the widespread use of spas, communal showers, and athletic shoes. Women experiencing any painful condition of the feet or hands should be referred to a podiatrist.

Treating nail infections. There are many new treatments available. Topical antifungal creams and "polishes," while easy to use, are not very effective. Systemic therapy and, in severe cases, podiatric removal of the nail either in part or total offer the best chances for cure. Recent studies have reported cure rates of 67% to 100% in patients treated with the newer systemic antifungals--fluconazole, itraconazole, and terbinafine.[14] Fingernail fungal infections usually are eradicated more quickly and completely than are toenail fungal infections. Drug-drug interactions, for example, with oral contraceptives, hypoglycemics, and some antibiotics, can occur with these new azoles, so careful monitoring is important (Table II).[15] Further, antifungal agents are not effective against all fungi. For example, terbinafine, commonly prescribed to treat onychomycosis, has a good safety profile but is not very effective in eradicating Candida infections.

Although the diagnosis of fungal nail infection is a clinical one, there are conditions, such as nail trauma, psoriasis, tumor, and chronic heart or lung disease, that can mimic this infection. Nail clippings or biopsy material sent for fungal culture can be helpful in prescribing treatment, which should take into account both the side effects (including drug interactions) and cost of treatment. Without prompt treatment, permanent nail damage (ridges, thickening, discoloration) or even nail loss can result.