Nail Diseases

MALALIGNMENT OF THE GREAT TOENAIL 39137096​​​

Background

• Definition: a nail that is deviated (usually laterally) from the distal phalanx.  

• This weakens the attachment to the nail bed, leads to thickening, yellow-grey-brown discoloration, transverse lines.

• Over time, chronic onycholysis leads to the the lateral nail folds and distal digit pulp "growing in" causing a diminution of the nail bed (disappearing nail bed sign). In basic terms, the chronic separation of the nail bed and plate causes epithelialization of the bed and perpetuates the problem. 

• ​Etiology is unknown, possibly genetic, possibly intrauterine insult.  50% of cases resolve by age 10.  Adults presenting with the condition usually endorse prior trauma but this may be delayed presentation of more mild congenital disease. 

Treatment

Conservative Management​

• Keep nails trimmed short to minimize trauma.

• Use keratolytic agents to soften thickened nails, making them easier to cut.

• Wear well-fitted or open-toed shoes to reduce pressure on the nail.

• Silicone or gel toe caps can protect the nail from trauma.

Cosmetic Solutions

• Acrylic molded nails for improved appearance, though caution is needed to avoid further damage.

• Cosmetic tattooing of the anonychia (absence of nail) after healing from matricectomy (see below)

Medical Interventions

• Steroids:

  • High-potency topical steroids or intralesional corticosteroid injections, especially for retronychia (embedded nails).

• Antifungals:

  • Treat concurrent fungal infections if present, but this does not resolve malalignment.

Surgical Interventions

• Realignment Surgery:

  • Unguodermal rotation flap for children or select teenagers with mild-to-moderate disease.

  • Best performed before age 5, though outcomes may vary in older patients.

• Partial or Total Nail Avulsion:

  • Strip avulsion with chemical matricectomy for severe cases with ingrown nails or hypertrophic lateral folds.

  • Total nail avulsion with complete matricectomy for "end-stage malalignment.​​​