Toenail disease is very common amongst our patients. Most of the conditions we see are related to the effects of trauma and dermatophyte infection. The results of these are often nails which are unsightly which may not always respond fully to treatment. Consequently, patients may seek a cosmetic solution. In this blog, I will look at a recent article reviewing the effect of prosthetic nail resin (PRN) or toenail reconstruction on a patient's wellbeing [1].
Unattractive Toenails
Patients present frequently in practice with damaged and deformed toenails, some of which can be improved, some of which cannot. For the cases of terminal nail dystrophy regular reduction and podiatry care or a total nail avulsion may be the only solutions available.
However, for some time, various podiatry suppliers have sold kits that allow practitioners to “reconstruct” nails using a synthetic resin cured, in layers by UV light, to produce an artificial nail that often looks much better than the offending nail pathology. This is a service offered by many podiatry clinics, but my interest was tweaked by a recent paper which looked at this very topic, researching the effects on patients' well-being after artificial toenail reconstruction.
Quality of life with nail disease
Quality of life measures have been around for a number of decades, but only a few have focussed on nail disease, with an early measure being validated back in 1992 [2] assessing the QOL of patients with onychomycosis and others that followed including Taboli, NailQ
with some measures focussing on specific diseases like the NAPPA & NPQ10 for nail psoriasis and the NPQ10 in alopecia related nail changes.
A study from the US involving podiatrists and dermatologists, investigated the benefit on QOL of nail resin in patients with retronychia deformity of the nails. Published in the Journal of the American Academy of Dermatology, the researchers recruited 15 patients (with a mean age 50 years old) with toenail dystrophy affecting one or both halluces (retronychia). They then completed a QOL measure adapted from an onychomycosis study [3], scoring their results before any treatment (with the deformed nail) and after treatment (nail drilling, drying and application of a prosthetic nail resin).
Results
Prior to treatment, 73% of patients were disappointed with previous treatments, 80% felt their nail(s) were unsightly, 87% being upset by their nail appearance and 73% feeling they are not able to wear their preferred shoes.
Following treatment and application of the PRN, QOL score improved significantly - 86% reported improved nail appearance, 86% no longer needed to hide their nails and 73% wanting to continue PRN use afterwards.
Are there any downsides to reconstructions?
Of course, following drilling of the old nail with application on top of PRN, as the old nail grows it will push the PRN forward creating a gap at the eponychium. In addition, a PRN is not naturally watertight to the nail bed like a normal nail so ingress of water can carry infection - particularly pseudomonas (See my earlier blog on this pathogen). One case was reported during this study. Consequently, it is recommended that the PRN is removed every 6-8 weeks,
Comment
Onychomycosis and psoriasis are a common cause of nail dystrophy and discoloration and for some patients it cannot be fully eradicated leading to a reduced quality of life [4, 5]. Although the idea of reconstructing nails may not be offered in every clinic, a dive into the psychology of healthy-looking nails is interesting. A study by Kawakubo & Ogawa [6] covers the topic well but interesting shows professionally administered nail care procedures improve a patients emotions, relaxation and self-esteem more than self-care.
Although this is one small scale study of PRN is from one institution, it is the first step in showing the positive patient related benefits of a simple cosmetic procedure. Further confirming research is always welcome but ultimately, if we are able to improve our patient’s sense of wellbeing, we are doing good a job.
References
1. Curtis, K.L., et al., Prosthetic resin nail improves quality of life in patients with retronychia in a single-center clinical trial. Journal of the American Academy of Dermatology, 2024.
2. Lubeck, D., et al., Quality of life of persons with onychomycosis. Quality of life research, 1993. 2: p. 341-348.
3. Drake, L.A., et al., The impact of onychomycosis on quality of life: development of an international onychomycosis-specific questionnaire to measure patient quality of life. J Am Acad Dermatol, 1999. 41(2 Pt 1): p. 189-96.
4. Milobratović, D., et al., Quality of life in patients with toenail onychomycosis. Mycoses, 2013. 56(5): p. 543-551.
5. Reich, A. and J.C. Szepietowski, Health-Related Quality of Life in Patients with Nail Disorders. American Journal of Clinical Dermatology, 2011. 12(5): p. 313-320.
6. Kawakubo, A. and T. Oguchi, Salon nail care with superficial self-disclosure vitalizes psychological state. Front Psychol, 2023. 14: p. 1112110.