Nail procedures can be simple, straightforward

Key Points

Hershey, Pa. - Contrary to what some clinicians believe, nail procedures are usually simple and straightforward, and dystrophies often can be avoided if proper care is taken.

According to one specialist, many dermatologists have an unfounded fear of these simple surgeries, possibly because of lack of training and experience.

"Some dermatologists do not do nail procedures because they may feel they did not get enough training during their residency, or they think the procedure may be more difficult than it actually is.

Nail dystrophy occurrence

Nail dystrophies occur when the nail matrix is damaged.

To help minimize the risk of a nail dystrophy, the surgeon should avoid inflicting damage to the proximal nail matrix, Dr. Billingsley tells Dermatology Times.

When a punch or shave biopsy is done in the nail matrix, the surgeon should try to limit the size to 3 mm or less to help minimize the trauma. This, in turn, can lower the risk of causing a nail dystrophy. Damaging the proximal matrix will cause a nail change that is at the top of the nail and is visible. Conversely, damage to the distal matrix produces a change that is on the underside of the nail and is less likely to be visible. If a biopsy must be done, it would be wise to do it in the distal matrix, if possible.

"When a patient presents with a nail plate change, or dystrophy, you know that something is clearly affecting the matrix and making the nail abnormal. This could be a benign tumor sitting on top of the matrix, an inflammatory dermatosis affecting the matrix or a malignant lesion that is destroying the matrix. To find the cause of this abnormality, you must remove the nail plate, inspect the matrix and the nail bed, locate the abnormality and perform a biopsy. Sometimes, you have a pigmented lesion, and you need to determine if it is a melanoma, nevus or a hematoma. Though they are not very common under the nail plate, a squamous cell carcinoma (SCC) can also occur in the nail unit. Subungual SCC is not as quickly discernable as SCC is on the skin or right next to the nail. Often, if they are underneath the nail, the nail will grow abnormally, and this warrants a biopsy as well," Dr. Billingsley says.

Avoiding damage

When performing a nail surgery, Dr. Billingsley says it is important that the surgeon is careful not to cause too much damage to the nail matrix, such as when performing hemostasis with cautery or by inflicting inadvertent damage with surgical instruments.

It is very important that the surgeon take the time to operate with care, and each movement should be made with purpose. Unnecessary matrix damage may come back to haunt the surgeon and the patient.

According to Dr. Billingsley, nail surgery does not have to be a painful procedure if it is performed correctly, and dermatologists need not worry about causing discomfort to the patient.

"Digital blocks are very effective and, if performed correctly, the patient will, at best, experience only minimal discomfort. It is very important here to administer the local anesthetic slowly and allow adequate time for it to take effect. Nail procedures such as nail avulsion and nail unit biopsies can be efficient and simple procedures.

"The important points for the physician to remember are to make the procedure as painless as possible, avoid the proximal matrix, if possible, and to discuss postoperative expectations clearly with the patient," Dr. Billingsley says.