Nail conditions - onychophosis, onychauxis and onychocryptosis.

Describe the aetiology, pathology, clinical appearance and treatment of onychophosis, onychauxis and onychocryptosis. Outline the main clinical features of an onychocryptosis.  State the management strategy that may be appropriate for this condition.Describe the changes that take place in the tissues during the development of onychocryptosis when hypergranulation and sepsis are present.Onychophosis is a nail condition where corn or callus is present in the nail sulcus.  CausesThe callus develops as a result of mechanical stresses, and where corns develop there must be localisation of pressure.  It may also develop as a complication of a sensitive sulcus, involution or onychauxis, wearing short, tight shoes, tight socks or stockings, badly cut toenails and having a thick, fleshy toe.PathologyThe pathological changes which occur in onychophosis are the formation of corn and callus.Clinical features Pain on pressure from footwear, manual pressure, pressure from bedclothes.  The corns may be very small or deep.  There will usually be one or more corns, which are hard or seed like.  The nail fold may be red or swollen (inflammation).  The lateral edge of the sulcus may appear distorted by being forced open by the mass of keratinised tissue.  There may also be distortion of the nail plate.  The nail plate may be involuted or thickened.  Callus can be seen in the nail sulcus and is yellow in colour.  It may also be rubbery in texture if associated with a relaxed sulcus.    Treatment Strict antiseptic precautions are taken throughout the treatment.  The nail should be cut straight across.  The thickness of the edge of the nail should be reduced.  A potassium soak could be used to facilitate the removal of callus or corn.  Callus should be removed with a scalpel or probe.  Corns should be enucleated with a No.15 scalpel blade.  Packing is usually applied under the sides of the nail, for example, chamois, cotton wool, foam or bactigras tulle.  A post-op medicament should be applied if appropriate, e.g. to treat inflammation use iodine or witch hazel.  For callus use salicylic acid. Onychauxis is a uniform thickening of the plate.CausesIt can develop for several reasons including, trauma, senility, clawing of the lesser toes, previous infections, medical disorders and skin diseases.  It can also be congenital.  PathologyThe main pathological changes which occur in onychauxis are eversion and shortening of the nail fold, and increased vascularity of the area.  Clincial features The nail appears thick, and is yellowish or white in colour.  It is also opaque.  The nail plate is usually very dry and brittle.  There may also be a considerable amount of corn/callus in the nail sulci or under the nail plate.  The nail plate is not closely attached to the nail bed.  The condition may affect one nail, several nails or all of the nails.  The patient may complain of pain or unsightliness.Treatment Strict antiseptic precautions are taken throughout the treatment.  The nail is reduced and debris, corn and callus is removed from the sulcus.  Application of a post-op medicament should be applied where appropriate.  Nail surgery could be considered if the treatment fails to give pain relief. Onychocryptosis is a nail condition in which the edge of the nail, or a splinter which remains attached to the nail plate has penetrated the tissues of the sulcus.  There may be an inflammatory reaction, hypergranulation tissue and possibly a secondary infection.Clinical featuresAffects more males than females and is more common in adolescents.  The lateral borders of the first toenails are most commonly affected - but the condition can also affect the medial borders.  The toe may be swollen and inflamed with bleeding.  Pus may be present.  The nail sulcus may be filled with hypergranulation tissue.  Their may be pain - a throbbing to sharp pain on palpation.CausesIt can develop as a result of a poor nail cutting technique, onychotillomania, trauma, onychorrhexis or abnormal foot mechanics.  Predisposing causes include: Involution, hyperhidrosis, maceration, relaxed sulcus, obesity, pronation, hyperextension of great toe.  Precipitating causes include hot, occlusive footwear, ill-fitting footwear, tight socks or hoisery, warm environment and athletic activity.  PathologyInflammatory reaction due to nail edge or splinter.  Pus formation.  Chronic inflammation due to foreign body remaining.  Hypergranulation tissue formation. Treatment Treatment begins with locating the splinter.  The splinter is then removed and the inflammation is reduced by applying Witch Hazel.  Any infection should be treated, and an antiseptic dressing applied.  Foot care advice should be given where appropriate.  Treatment should be given for the predisposing causes.  If appropriate, total or partial nail avulsion may be carried out.

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