Nail avulsion: Indications and methods (surgical nail avulsion)

Deepika Pandhi, Prashant Verma Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, University of Delhi, Delhi, India

Correspondence Address :
Deepika Pandhi
Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, University of Delhi, Delhi 110 095
India
copyright : ( C ) 2012 indian Journal of Dermatology, Venereology, and Leprology

The nail is a subject of ball-shaped importance for dermatologists, podiatrists and surgeons. Nail avulsion is a frequently undertaken, so far simpleton, challenging procedure. It may either be surgical or chemical, using 40 % urea. The erstwhile is most often undertake using the distal access. Nail avulsion may either be utilitarian for diagnostic purposes like exploration of the pinpoint bed, complete matrix and the breeze through folds and before contemplating a biopsy on the smash bed or for curative purposes like onychocryptosis, warts, onychomycosis, chronic paronychia, nail tumors, matricectomy and retronychia. The routine is carried out largely under local anesthesia with or without epinephrine ( 1:2,00,000 dilution ). Besides the above-mentioned indications, the contraindications and complications of pinpoint avulsion are concisely outlined. Keywords: Chemical, onychomycosis, paronychia, surgical complete avulsion, wart Introduction
Nail avulsion, the interval of the collar denture from the surrounding structures, is the most frequently performed surgical or nonsurgical, chemical operation on the nail down unit. It may either be utilitarian to explore the nail unit for diagnostic purposes or as a curative tool in particular nail pathologies. Nail avulsion may be accomplished using either a distal or a proximal anatomic set about. The former is the most frequently used technique, in which the nail plate is released from its attachment from the smash layer at the hyponychium, [ 1 ] while in the latter, the collar plate is separated from the proximal nail fold ( PNF ) followed by a complete separation moving distally. [ 1 ] Chemical complete avulsion by using urea ointments is a valuable technique that avoids the complications encountered with its surgical counterpart. The current dissertation is an enterprise to bring about the salient brief of the topic succinctly .
Applied Anatomy
It is imperative to understand the anatomy of the complete and the intricacies of nail growth prior to undertaking collar avulsion. Nails are ectodermal appendages covering the dorsal aspects of the digits. [ 2 ]
These structures provide security and integrity to the fingertip, in addition to facilitating skilled hand functions. consequently, an abnormal alteration in the anatomy of the breeze through unit may interfere with the aforesaid functions. The distal border of the smash is free, while the proximal border is clutched into a fold and is covered with a hide flap called the eponychium or cuticle [ Figure – 1 ]. The collar is attached at its lateral, distal and proximal borders. The collar bed, besides called the sterile matrix, anchors the dermis to the periosteum of the distal phalanx. The matrix has been divided into distal sterile matrix ( breeze through seam ), which is covered with originate collar, average matrix that corresponds to the epithelial line of the ventral open of the PNF, and the distal germinal matrix, from which a newfangled nail arises. The germinal matrix is covered with the eponychium. [ 2 ]

Figure 1: Anatomy of nail

The lunula is the pale crescent structure well recognized under the proximal fortune of the nail. importantly, the nail down is not firm attached at the lunula. Because the collar is formed in the germinal matrix, loss or disfigurement of this depart results in permanent personnel casualty or permanent disfigurement of the nail. As the nail grows distally, the superficial cells become cornified. Distal to the lunula, the nail down is hard attached to the pinpoint layer or aseptic matrix. [ 2 ] Complete regrowth of an avulse finger nail normally requires 4-5 months ( 1 mm/week ), whereas the toe breeze through may require up to 10-12 months. It is substantive to preserve the skin folds surrounding the breeze through margins. Wide scars or misalignment in the skin fold can result in rending or permanent deformity of the pinpoint when it regrows. Adhesions between the eponychium, pinpoint bed and matrix are prevented by maintaining this space with either the supplant smash or gauze backpack. The skin of the complete bed is supported by a highly vascularized hypodermic level that well links the nail bed to the abaxial periosteum of the distal phalanx. [ 3 ] The subungual glomus is a ample vascular network of microscopic vessels situated in the hypodermic tissue deep to the pinpoint go to bed, and plays a function in peripheral temperature rule. Distal to the hyponychium and plantar to the medial and lateral pass nail down folds ( LNF ), the digital pulp surrounds the distal phalanx and convey vessels and nerves to and from the toe tip .
Indications of Nail Avulsion
Nail avulsion is the most common surgical procedure performed on the nail unit. The nail plate is excised from its prime attachments, the complete bed ventrally and the PNF dorsally. The indications of nail avulsion are outlined as follows :
Diagnostic
Nail avulsion is frequently undertaken as a preliminary step for the watch indications : [ 4 ]

  • Exploration of the nail bed and the nail matrix: This may be required in order to look for the pathologies originating in either the nail bed or the nail matrix, which include inflammatory dermatoses, infections, connective tissue diseases and tumors. On the other hand, a disease process affecting the surrounding tissues may encroach on the nail bed.
  • Exploration of the PNF and the LNF: A complete exposure of these structures to divulge the extent of a disease may require a nail avulsion.
  • Performing biopsy on the nail bed and the nail matrix: Many a times, nail avulsion is performed to uncover the nail bed and matrix for the purpose of a biopsy. This is often the situation in diseases like psoriasis, lichen planus, twenty nail dystrophy, nail unit tumors, nevi, melanonychia and pachyonychia congenita.

Therapeutic
other than the aforesaid indications, smash avulsion is used as a curative adjunct for the follow indications :

  • Before a chemical or surgical matricectomy: Matricectomy refers to the complete extirpation of the nail matrix, resulting in permanent nail loss. Usually, however, matricectomy is only partial, restricted to one or both lateral horns of the matrix. Nail ablation is the definitive removal of the entire nail organ. The most important common denominator in a successful matricectomy is the total removal or destruction of the matrix tissue. Matricectomy may be indicated for the management of onychauxis, onychogryphosis, congenital nail dystrophies and chronic painful nail, such as recalcitrant ingrown toenail or split within the medial or lateral one-third of the nail.
  • Ingrown toe nail/onychocryptosis: Indications for the treatment of an ingrown toenail include significant pain or infection, onychogryphosis (a deformed and curved nail) or chronic, recurrent paronychia (inflammation of the nail fold). The most common procedure to treat locally infected ingrown toenails is partial avulsion of the lateral edge of the nail followed by chemical matricectomy using 80-88% phenol (phenolization). [5],[6] In a randomized study [7] comprising 117 patients, patients underwent partial nail avulsion in combination with either excision of the matrix or application of phenol, with or without local application of gentamicin afterwards. The measured endpoints were infection at 1 week and recurrence at 1 year. Infection rates were found unrelated to the use of antibiotics. However, recurrence rates were found to be significantly lower after phenolization of the nail bed (13.8%) compared with excision of the nail matrix (38.9%). Contrary to this, another randomized trial comprising 63 patients found both partial nail avulsion with phenolisation or with partial matricectomy to be equally effective. [8] Besides, a remarkably low incidence of recurrence (0.6%) and wound infection (2%) has been found. The mean time to return to normal activities is 2.1 weeks. [9]
  • Chronic onychomycosis: Thirteen patients with distal subungual onychomycosis in a total of 48 dermatophyte-infected nails were treated with chemomechanical, partial nail avulsion followed by topical miconazole for 8 weeks. Periungual skin irritation was common during the initial avulsion period. The clinical and mycological cure rate was 42% at 6 months after cessation of therapy. The therapeutic response was related to the pretreatment extension of subungual hyperkeratosis. This treatment modality could be a valuable alternative to other remedies for the treatment of onychomycosis limited to a few nails. [10] Total nail avulsion has been found to be effective, especially for patients with single- or oligo-onychomycosis [Figure – 2] and in those with a dubious diagnosis. [11] In contrast, another randomized trial comprising 40 subjects with single-nail onychomycosis recorded a high drop-out rate. All cases of total dystrophic onychomycosis failed to respond to this therapy. Overall, 15 of 27 (56%) patients were cured with this approach. No side-effects or long-term complications of the nail avulsion were encountered. [12]
  • Figure 2: Distal subungual onychomycosis involving a single nail with evidence of onychogryphosis
  • Traumatic nail injuries: Avulsion may be used to evaluate the stability of the nail bed or to release a subungual hematoma after failed puncture aspiration. If sufficient blunt or sharp force is applied to the nail plate and surrounding folds, it can violate the structural integrity of the nail bed and the resultant hemorrhage can fill the potential space that normally exists between the nail plate and the underlying nail bed. The force of the injury as well as the hemorrhagic response can separate the nail plate from the bed, causing traumatic onycholysis. If the force is sufficient enough, the proximal margin of the plate will often separate from the matrix region under the PNF and elevate through the nail fold. This disrupts the seal of the cuticle and potentially exposes the underlying tissues to bacterial contamination. If there is an associated fracture, the patient may be at risk for distal phalangeal osteomyelitis. [13] Whenever a patient presents with an acutely injured, throbbing toe with a subungual hematoma, one should consider disruption of the nail plate. If the patient maintains structural integrity of the nail folds and there is disruption of the nail bed, subungual pressure secondary to hemorrhage can cause persistent digital pain that may last for several hours to several days, and simply draining the hematoma will usually provide relief. There are many ways to drain a painful subungual hematoma safely. The method one uses is based on the structural integrity of the nail folds and the amount of the visible nail plate associated with the hematoma. As a rule, when there are stable nail folds and an injury displaying less than 25% of the visible nail plate associated with the hematoma, one can drain the hematoma through the nail plate. [14] If the subungual hematoma involves greater than 25% of the visible nail plate and/or the nail plate has been avulsed in such a way as to disrupt the proximal, medial or LNF contiguous with the bed, then a significant nail bed laceration is likely. Accordingly, one should remove the entire plate in order to facilitate direct visualization and surgical repair of the nail bed. Severe stabbing or plantar flexor injuries can cause nail bed laceration and phalangeal fractures that propagate along the dorsal surface of the nail plate into the PNF and through the physeal plate of the distal phalanx, separating the nail plate from the ventral surface of the PNF. [15] When this occurs, the basilar epiphysis is usually displaced dorsal relative to the nail bed because the epiphysis remains anchored to the interphalangeal collateral ligaments and the extensor tendon. [16] One would treat this injury by removing the nail plate or at least the proximal portion of the nail plate and following-up with cleansing, debridement and inspection.
  • Chronic paronychia: It is an extremely recalcitrant dermatosis that is particularly prevalent in housewives. Medical treatment for this condition is unsatisfactory in a significant number of cases. [17] In these patients, no response is evident to irritant avoidance and topical therapy and surgical approach forms a vital part of management. An en bloc excision of the PNF combined with a total, or more commonly partial, restricted to the base of the nail plate, nail plate avulsion has been shown to be a useful method in chronic, recalcitrant paronychia, especially where the PNF is fibrosed or thickened. [17] Alternatively, an eponychial marsupialization, with or without nail removal, may be performed. This technique involves excision of a semicircular skin section proximal to the nail fold and parallel to the eponychium, expanding to the edge of the nail fold on both sides. [18]
  • Retronychia: It is defined as a reverse embedding of the nail plate into the PNF, a result of persistent nail fold inflammation. Nail plate avulsion with supplementary medical management is curative. [19]
  • Pincer nails (“Omega nails” and “Trumpet nails”; [Figure – 3]): A toenail disorder in which the lateral edges of the nail slowly approach one another compressing the nailbed and the underlying dermis. It occurs less often in the fingernails and is usually asymptomatic. Pincer nails are not amenable to surgical nail techniques as these do not affect the underlying bony alterations, which is the primary pathology. Repeated nail avulsion at regular intervals using 40% urea was found to be effective in a 39-year-old woman with hereditary pincer nails. [20] Persistent pincer nail deformity was also effectively treated with nail avulsion and CO 2 laser matricectomy in a 63-year-old man. [21] However, caution is warranted as repeated surgical nail avulsions may worsen the curvature of nails and further increase the transverse curvature of hallux nails. [22] Widening of the nail bed followed by splinting has recently been recommended. [23] Nonetheless, complete surgical nail ablation or phenolisation is the only ultimate remedy for pincer nails. Nail avulsion followed by osteophyte removal and broadening the nail bed has also been claimed to be effective. [22]
  • Figure 3: Pincer nail
  • Warts: It is the most common nail tumor, and mostly affects children and young adults. Periungual warts [Figure – 4] are usually due to HPV-1, 2 and 4. Development of periungual warts is favored by maceration and trauma, especially nail biting. The natural course of warts restricts aggressive approaches to selected cases. Partial or complete nail avulsion is indicated for exploring the extent of involvement of nail bed or matrix with HPV and also to ensure complete eradication of diseased tissue. Medical treatments, usually topical, include keratolytic agents, virucidal agents and immunomodulators. All choices have been utilized successfully, but keratolytic agents are the best first-line approach. Surgical treatments include cryotherapy, surgical excision, electrosurgery, infrared coagulation, localized heating with a radiofrequency heat generator and laser therapy, especially the Er: YAG laser. Recalcitrant periungual verrucae (24 lesions) in 17 patients were vaporized with the carbon dioxide laser in combination with partial or complete nail avulsion. [24] A complete cure rate of 71% was observed in patients who had one or two treatments. The cure rate increased to 94% in patients who underwent one or two laser treatments in combination with other therapies. Postoperative pain was short lived and infection and significant onychodystrophy were uncommon.
  • Figure 4: Wart on the lateral nail fold encroaching on nail bed and matrix resulting in destruction of the nail plate. Partial nail avulsion is indicated to determine the extent of the wart
  • Tumors: Nail plate avulsion combined with nail bed excision forms the treatment for the following tumors:

    1. Onychomatricoma: It is a rare nail matrix tumor with specific clinical and histologic features, including a macroscopic appearance of filiform digitations originating from the nail matrix that are inserted in the nail plate. [25] Onychomatricoma has a classical clinical appearance; however, it is difficult to identify, as it is not until surgery, when the typical filiform projections are more visible that the diagnosis can be made. [26]
    2. Glomus tumor [Figure – 5]: It is a painful subcutaneous nodule, commonly occurring in the subungual regions, and is accompanied by tenderness and temperature sensitivity. In the treatment of subungual glomus tumor, surgical excision is known to be the only curative method. It is challenging to minimize postoperative nail deformity and yet to ensure a low incidence of tumor recurrence. [27] The transungual approach with nail avulsion and an incision selected according to the tumor location can produce an excellent outcome with minimal postoperative complications. Dressing with a trimmed nail plate may also be beneficial in managing the wound. [28]
    3. Miscellaneous: Melanoma and nonmelanoma cancers, pyogenic granuloma, fibrokeratoma and exostoses are the other tumors that may require a nail avulsion as a preliminary procedure. [3]
      Figure 5: Distal nail plate showing henna staining and intensely painful dusky erythematous lesion (arrow) under the nail plate, which was diagnosed as Glomus tumor

Contraindications
proportional contraindications to performing operating room in the breeze through unit are outlined as follows [ 3 ] :

  • Peripheral vascular disease
  • Collagen vascular disease
  • Diabetes mellitus
  • Disorders of hemostasis
  • Acute infection or inflammation of the nail unit, including the surrounding paronychial tissues

Procedures of Nail Avulsion
Distal [ 3 ], [ 29 ], [ 30 ], [ 31 ] and proximal avulsion are the two surgical approaches for undertaking complete avulsion. [ 29 ], [ 32 ] Chemical avulsion with urea glue is another valid nonsurgical proficiency that may be used in certain situations. A overtone or dispatch complete avulsion can be performed, depending on the location and extent of disease. Nail avulsion, however, is not a definitive cure in cases of complete dystrophy caused by onychocryptosis, nail matrix disease [ 33 ] or across-the-board nail bed pathology.

Anesthesia
Before avulsion, anesthesia of the digit is achieved through a digital block performed with 1 % lidocaine. [ 34 ]
There are two schools of think on the use of epinephrine with lidocaine in the context of digital anesthesia. By convention, when administering an anesthetic for nail down operation, the practice of epinephrine should be avoided, particularly in patients with a history of extensive vascular disease. consequently, patients with a history of thrombotic or vasospastic disease and uncontrolled high blood pressure should not receive epinephrine. [ 3 ] Epinephrine has vasoconstricting properties, and it has been associated with necrosis and poor wind heal of tissues, while others believe that these complications appear to be largely theoretical and have rarely been noted to occur in rehearse. Proper injection proficiency and adequate choice of patients are recommended to minimize complications. A concentration of 1:2,00,000 is deemed as condom. indeed, in a study, epinephrine-supplemented local anesthetics were used for the ear and nose operating room without any meaning complications in more than 10,000 surgical procedures. [ 35 ] Further, skin rake menstruate was studied at the fingerpads via laser Doppler flowmetry over the course of 24 planck’s constant in a prospective, double-blind, randomized, placebo-controlled report with 20 vascularly healthy test persons. It was shown that epinephrine additive in local anesthesia decreased blood flow by less than 55 % after a period of 16 min. [ 36 ] In however another study, there were 3110 consecutive cases of elective course injection of low-dose epinephrine ( 1:100,000 or less ) in the hand and fingers and no case of digital tissue passing was documented. [ 37 ] In fact, a sum of 50 cases of digital necrose have been documented in the literature, of which 21 were associated with the use of epinephrine ; however, this was prior to 1950, when procaine was used as an anesthetic and the concentration of epinephrine used was eminent. The epinephrine digital infarct cases that created the dogma are invalid because they were besides injected with either procaine or cocaine, which were both known to cause digital infarct on their own, and none of the 21 epinephrine infarct cases had an try at phentolamine rescue. [ 38 ] In fact, the addition of epinephrine reduces the want for the consumption of tourniquets and large volumes of anesthetic and provides a better and longer pain dominance during digital procedures. Exsanguinating compression bandage may be used to minimize run ; however, it should be released every 15 min for a few minutes to prevent necrose. [ 39 ]
diverse methods have been suggested to reduce the trouble while injecting a local anesthetic. accession of sodium bicarbonate reduces the stick sensation related to the acidic nature of epinephrine containing local anesthetic. sedation with a combination of sedatives, analgesics and tranquilizers is helpful. This places the patient in a quiescent department of state so that local anesthetic and steel blocks may be well administered. In addition, repetitive, rapid pilfer and shake of the hide proximal to the site of injection during lignocaine percolation works on the “ gate control hypothesis. ” [ 40 ]
Methods
Nail avulsion surgery is frequently accomplished using a smash elevator device. In addition, a mosquito hemostat or a dental spatula may besides be used for the purpose. In distal pinpoint avulsion [ Figure – 6 ] a-d, the instrument is introduced under the distal free edge of the complete home plate so that the nail plate can be separated from the underlying breeze through bed hyponychium. The nail plate is then separated from the underlying nail bed directed proximally towards the matrix, with meaning resistance occurring until the matrix is reached. As the matrix is reached, the surgeon experiences a sudden decrease in resistor. subsequently, the elevator [ Figure – 7 ] is reinserted with respective longitudinal and side to side strokes to detach the nail plate from the nail bed wholly. Thereafter, the elevator is inserted under the PNF in the proximal collar groove between the eponychium and the nail home plate to release the fastening. This step should be a ennoble one so as to avoid accidental injury. [ 33 ]

Figure 6a: Distal nail avulsion in a case of chronic paronychia with proximal nail fold fibrosis and dystrophic nail plate. The plate is being avulsed in addition to crescentic excision of the proximal nail fold Figure 6b: Freeing of the lateral nail fold Figure 6c: Lifting of the nail plate from the nail bed with lateral sweeping movement Figure 6d: Vascular nail bed after separation of the nail plate
Figure 7: Freer’s elevator

Proximal nail down avulsion is preferred in the bearing of distal nail dystrophy, in which it is frequently not possible to access the distal dislodge edge of the pinpoint plate. This site is often encountered in distal subungual onychomycosis. [ 29 ], [ 32 ], [ 41 ] The Freer elevator is inserted beneath the cuticle in the proximal groove to separate the PNF from the nail plate. then, it is reoriented so as to allow its concave open to accommodate the swerve surface of the adaxial surface of the pinpoint plate. [ 42 ] The instrument is advanced until it ultimately reaches the distal edge of the nail denture .
secondary bacterial infections can be a cause of considerable morbidity in nail avulsion, specially in toe nails. Intraoperative antiseptic nail irrigation has, therefore, been recommended to reduce bacterial contamination. [ 43 ]
Alternatives to the aforesaid pinpoint avulsion methods have been described. In many cases, fond smash plate avulsion is preferable compared with traditional total distal and proximal plate avulsions. The techniques described herein include partial distal, lateral, proximal and window techniques and two variations of the full denture avulsion termed the trap door and lateral collar plate curl up avulsion. [ 44 ] By using these methods, the surgeon is able to access the target nail down whole while minimizing injury to the adjacent, degage weave .
Chemical nail avulsion
Forty percentage urea ointment is much used in the discussion of onychomycosis, onychogryphosis, psoriasis and candidal and bacterial infections. [ 45 ], [ 46 ], [ 47 ] Urea ointment paste is formulated to include 40 % urea, 5 % white beeswax or methane series, 20 % anhydrous lanolin and 35 % white petrolatum. [ 45 ], [ 46 ] Urea acts by dissolving the bond between the nail down layer and the nail down plate, and it besides softens the pinpoint home plate. The paronychial area is protected with adhesive material tape before applying urea paste to prevent chemical discomfort of the soft tissues. The ointment is liberally applied to the nail plate, and hypoallergenic videotape is used to create a well around the process thickened nail to hold the glue. [ 47 ] The affected role is instructed to keep the collar occluded and to avoid wetting the cover area. After 1 workweek of blockage, the dystrophic nail down is removed by using a pinpoint elevator and a breeze through limiter. In onychomycosis, antifungals may be prescribed as an adjunct. however, surgical pinpoint avulsion followed by topical antifungal therapy can not be recommended for the treatment of onychomycosis as it is frequently associated with a high dropout rate and poor conformity. [ 12 ] Dystrophic nails may respond better to chemical avulsion, and it is the ideal management for symptomatic dystrophic nails in patients with diabetic neuropathy, vascular disease or immunosuppression. [ 45 ] In addition, chemical avulsion may be used as a palliative, pain-relieving therapy in onychogryphosis. Minimal to absent pain, a low hazard of infection, shed blood and lesser downtime are the advantages of chemical over surgical avulsion. [ 45 ] Requirement of prolong application and irritation are some disadvantages of the procedure. Further, patients with gross deepening of the pinpoint without significant breeze through dystrophy may respond ill to chemical avulsion due to poor penetration. [ 45 ] Superficial abrasion of the nail plate may be worthwhile to foster the penetration of urea. contamination with water and poor people blockage may lead to treatment failure. Preparations other than 40 % urea have besides been tried. A combination of 20 % urea and 10 % salicylic acid ointment under a 2-week occluded front has been efficaciously used for minimally dystrophic nails. [ 30 ] Besides, a nail lacquer formulation containing 40 % urea in a film-forming solution has been devised. In a discipline comprising 10 patients of onychomycosis, the urea breeze through lacquer was applied with a brush twice a day for 1 workweek by the patient and for a foster week in two patients presenting with entire dystrophic onychomycosis. This facilitate easy removal of pinpoint and was well tolerated. [ 48 ] In another analyze consist of 13 patients of onychomycosis, a solution of 1 % fluconazole and 20 % urea in a mix of ethyl alcohol and water applied once daily at bedtime showed a golden response. [ 49 ] Phenolization is a well-conceived method of chemical matricectomy. In this procedure, 88 % carbolic acid is applied to the smash matrix while wish is taken to avoid contamination with any ointment applied in the vicinity. It may be applied in three cycles of 30 randomness each. Phenol has to be applied with the compression bandage on, so as to ensure a ashen field, as blood is known to inactivate carbolic acid. finally, carbolic acid is neutralised with isopropyl alcohol and an allow snip is done. [ 50 ] In a randomize discipline conducted on 148 ingrowing nails ( grade 2-3 ) of 110 patients, 1-min phenol cautery of the germinal matrix was found to have a better guard profile than drawn-out applications in the discussion of ingrowing nails. [ 51 ] Unpredictable tissue damage and prolonged healing time are the disadvantages of phenolization. recently, the partial avulsion of the affected edge and treatment of the germinal matrix for 1 min with 10 % sodium hydroxide preceded by matrix curettage has been found to be an effective and safe discussion mood for ingrowing toenails in people with diabetes. [ 52 ]
Sodium hydroxide is an alternate chemical agent that has been claimed to cause less weave damage as compared to phenol. Matricectomy with 10 % sodium hydroxide, either applied for 2 minute or 1 min combined with curettage, is equally effective in the treatment of ingrowing toenails with eminent success rates and minimal postoperative morbidity. [ 53 ] In a study comprising 46 patients, 154 ingrowing nail sides were treated with either sodium hydroxide or carbolic acid matricectomy. Both sodium hydroxide and carbolic acid were found to be effective giving high gear success rates, but sodium hydroxide caused less postoperative unwholesomeness and provided faster recovery. [ 54 ]
Laser nail avulsion
The use of carbon paper dioxide laser has recently been well described. A 63-year-old homo was evaluated and treated with the carbon dioxide laser for a persistent pincer nail down deformity. The affected role tolerated the procedure good and had an acceptable surgical result. [ 21 ] In another analyze, 196 consecutive patients previously unsuccessfully treated by surgery undergo successful CO 2 laser ( 5 W, defocused 2 millimeter beam in continuous mode ) operating room for perennial onychocryptosis. [ 55 ] Partial pinpoint avulsion followed by matricectomy with pulse CO 2 laser in the discussion of ingrowing toenails resulted in a high bring around rate, short circuit postoperative trouble duration and low risk of infection. [ 56 ] Recalcitrant periungual wart ( 24 lesions ) in 17 patients were successfully treated with CO 2 laser vaporization. [ 57 ] Vaporization of these warts, in combination with fond or complete pinpoint avulsion, resulted in complete cures in 71 % of the patients who underwent one or two treatments. infection and meaning onychodystrophy were rare. pain was largely short lived. Thus, laser therapy in combination with smash avulsion improves the therapeutic consequence and reduces complications .
Postoperative care
meticulous postoperative care is essential for a successful nail avulsion. A nonadherent, highly absorbant dress is ideal. It may be kept in set with either an elastoplast or a composition tape. The latter is less sticky and convenient to remove. The lateral pass grooves may be studded with either a paraffin gauze or an antibiotic tulle. [ 1 ], [ 3 ], [ 4 ] Dressing may be removed after 24 hydrogen after soaking in affectionate water system or saline. It is an satisfactory rehearse to soak the operate area in warm water twice a day. In summation, the povidone-iodine solution application may promote the bring around summons. The affected role should be advised to keep the operate on limb elevated so as to minimize the pain and well. Besides, minimal bodily process with the involved limb, specially if toenails are avulsed, should be carried out for at least 2 weeks .
Complications

Complications are rarely encountered in nail avulsion. These largely result from breeze through matrix price and present with postoperative nail down deformity. pain is the most common complication following nail avulsion. It is normally of curtly duration and responds well to analgesics. [ 58 ] Allergy to anesthetic, minor hurt discharge, infection, hematoma, collar deformity, malalignment, nail impingement ( distal implant ), local spicule increase and persistent annoyance and well up are the other adverse sequela. Complications may be avoided by adequate preventive measures, such as judicious patient choice, aseptic technique and gentle treatment of the complete matrix. [ 59 ]
Conclusion
Nail avulsion is a subject that has not been paid attention to by dermatologists. One needs to be well-versed with the anatomy of the nail while undertaking a pinpoint avulsion to avoid matrix and nail flock injury. full nail avulsion has been the conventional method acting to deal with assorted complete unit of measurement pathologies ; however, fond avulsion has gained popularity due to its simplicity and fewer postoperative complications. Ingrown toe nail, chronic onychomycosis and periungual warts continue to be the most coarse indications for nail avulsion. careful affected role selection and maintenance of asepsis during and after the procedure and gentle cover of matrix and nail folds are the key to superscript outcomes of the procedure .

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