Congenital Malalignment of the Great Toenail, the Disappearing Nail Bed, and Distal Phalanx Deviation: A Review

Buttars, Benjamin; Scott, Steven Gates; Glinka, Danielle; Daniel, C. Ralph; Braswell, Mark A.

doi:10.1159/000518477

Cited by 6 publications

(6 citation statements)

References 30 publications

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“…It is probably also a barrier to fungal infection of the distal nail bed [58]. Malposition of the nail be it due to malalignment of the nail itself, displacement of the distal phalanx or hallux valgus, results in chronic repeated microtrauma to the nail resulting in subungual hyperkeratosis, onycholysis, paronychia, Beau's lines, onychomadesis, and onychomycosis [58,62,63]. Onycholysis, too short a nail or lack of the nail of the big toe after nail avulsion or traumatic nail loss lead to a distal bulge and a shortened or disappeared nail bed [64,65].…”

Section: Discussionmentioning

confidence: 99%

“…However, it has to be stressed that subungual hyperkeratosis and true nail thickening are often erroneously seen as the same [67]. A malaligned nail or a laterally displaced toe are prone to sustain trauma through torsion stress forces during walking, crawling and from footwear [63]. It appears that compression forces that hit a deviated nail are of particularly devastating action on the attachment of the nail to the nail bed [15].…”

Section: Discussionmentioning

confidence: 99%

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Onychomycosis in Foot and Toe Malformations

Haneke

2024

Preprint

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Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses . However, the role of direct trauma in the pathogenesis of fungal nail infections was only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated.Aim of the study: This is a multicenter single-author observational study over a period of 6 years performed at a specialized nail clinic in three countries. All patient photographs taken by the author during this period were screened for toenail alterations and all toe onychomycosis cases were checked whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture or polymerase chain reaction (PCR) were accepted.Results: Of 1653 cases, 185 were onychomycoses proven by mycologic culture, PCR or histopathology. Of these, 179 involved at least one big toenail, 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease and the onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), hallux erectus was observed in 43 patients, the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role for the localization of the fungal infection as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency and iatrogenic immunosuppression whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or to correct. Generally, when explaining the treatment of onychomycoses to the patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Onychomycosis in Foot and Toe Malformations

Haneke

2024

Preprint

View full text Add to dashboard Cite

show abstract

“…It is probably also a barrier to fungal infection of the distal nail bed [57]. Malposition of the nail, be it due to malalignment of the nail itself, displacement of the distal phalanx, or hallux valgus, results in chronic repeated microtrauma to the nail, resulting in subungual hyperkeratosis, onycholysis, paronychia, Beau's lines, onychomadesis, and onychomycosis [57,61,62]. Onycholysis, too short a nail, or lack of the nail of the big toe after nail avulsion or traumatic nail loss, leads to a distal bulge and a shortened or disappeared nail bed [63,64].…”

Section: Discussionmentioning

confidence: 99%

“…However, it has to be stressed that subungual hyperkeratosis and true nail thickening are often erroneously seen as the same [ 67 ]. A malaligned nail or a laterally displaced toe is prone to sustain trauma through torsion stress forces during walking, crawling, or from footwear [ 62 ]. It appears that compression forces that hit a deviated nail are of particularly devastating action on the attachment of the nail to the nail bed [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

Onychomycosis in Foot and Toe Malformations

Haneke

2024

JoF

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Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses. However, the role of direct trauma in the pathogenesis of fungal nail infections has only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated. Aimof the study: This is a multicenter single-author observational study over a period of 6 years performed at specialized nail clinics in three countries. All patient photographs taken by the author during this period were screened for toenail alterations, and all toe onychomycosis cases were checked for whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe, and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture, or polymerase chain reaction (PCR) were accepted. Results: Of 1653 cases, 185 were onychomycoses, proven by mycologic culture, PCR, or histopathology. Of these, 179 involved at least one big toenail, and 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease, and onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), while hallux erectus was observed in 43 patients, and the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role in the localization of the fungal infection, as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with a determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration, and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency, and iatrogenic immunosuppression, whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or correct. Generally, when explaining the treatment of onychomycoses to patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.

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“…Lastly, the observance of the undulating nail surface has been explained as caused by recurrent onychomadesis (only implying periodic lamellar shedding), application of forces that cause a physical torque motion or by the repetitive backward pushing of successive generations of nail back into the nail pocket [10,17,20,38]. The regular succession of these suggests repeated trauma, nail lamellae that are periodically pushed back and again produce stacked polymeronychia.…”

Section: The Clinical Manifestations Of Retronychiamentioning

confidence: 99%

Classification of Retronychia: A Narrative Clinical Review

Lencastre,

Richert

2024

Skin Appendage Disord

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Background: A retronychia classification system is overdue considering the most recent publications. Using the keyword “retronychia”, publications with a narrative literature review were selected from PubMed/MEDLINE, EMBASE and Google Scholar, adding a few select papers. Summary: This article proposes a theoretical pathophysiological basis for retronychia. Several factors alter the clinical picture of retronychia: length and periodicity of backward displacement, duration of disease, intensity of paronychia, presence and type of nail stacking (polymeronychia), and remodeling of the nail apparatus (elevation of the proximal nail, nail bed shortening, retroversion of the distal nail fold and acquired malalignment). Key Messages: With these factors in mind, we propose a new classification system for retronychia: A standing for acute, O for ongoing, and C for chronic. We believe this easy system may increase the diagnostic acuity for the disease and its understanding.

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Congenital Malalignment of the Great Toenail, the Disappearing Nail Bed, and Distal Phalanx Deviation: A Review

Cited by 6 publications

References 30 publications

Onychomycosis in Foot and Toe Malformations

Onychomycosis in Foot and Toe Malformations

Onychomycosis in Foot and Toe Malformations

Classification of Retronychia: A Narrative Clinical Review

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