Green Nail Syndrome Treated with the Application of Tobramycin Eye Drop

Abstract

Green nail syndrome (chromonychia) is a nail disorder characterized by onycholysis and green-black discoloration of the nail bed. This condition is often associated with chronic paronychia. Pseudomonas aeruginosa is the most commonly identified organism in cultures from the affected area. Despite the various treatment options available, removal of the nail is still necessary in many cases. A 35-year-old man presented with dark-greenish discoloration of the nail plate and onycholysis on the left thumbnail. He had been treated with oral antifungal and antibiotic agents for several months; however, the lesion showed no improvement. The diagnosis of green nail syndrome was established after a positive bacterial culture, and on the basis of the antibiotic sensitivity test result, tobramycin eye drop (Tobrex®) was then prescribed. Three weeks later, the nail discoloration almost vanished but the onycholysis remained. Herein, we recommend the application of tobramycin eye drop as an easy and safe treatment option for green nail syndrome.

Keywords: Eye drop, Green nail syndrome, Pseudomonas aeruginosa, Tobramycin

INTRODUCTION

Green nail syndrome (chromonychia) is a nail disorder characterized by onycholysis and green-black discoloration of the nail bed. Pseudomonas aeruginosa is the most commonly identified organism in cultures from the affected area^1,2. Patients usually have a history of long duration of exposure to water or moist conditions, providing an ideal condition for the growth of P. aeruginosa, which is unable to colonize dry environments. Although various treatment options are available, treatment is always challenging and often refractory. This patient with green nail syndrome experienced a dramatic improvement by using tobramycin eye drop. Hence, we recommend the application of tobramycin eye drop as an easy and safe treatment option for green nail syndrome.

CASE REPORT

An otherwise healthy 35-year-old man presented with onycholysis of the middle to distal part of the nail of the left thumb along with dark-greenish discoloration in the separated portion of the nail. He remembered that the lesion was persistent and had been present for more than a year. He was an office worker and denied any history of trauma. He used to go swimming as a hobby. Although he had been treated with an oral antifungal agent (itraconazole, 200 mg/d) and an oral antibiotic (levofloxacin, 200 mg/d) for several weeks at another dermatologic clinic, the skin lesion showed no improvement. Physical examination of the left thumbnail revealed dark-greenish pigmentation and onycholysis (). Neither paronychia nor eczematous lesion was found around the affected nail. The nails of the other fingers and toes were grossly normal in appearance.

The distal two-thirds of the left thumbnail showing dark-greenish pigmentation and onycholysis.

Direct light microscopy of a sample from the clipped nail debridement was negative for fungal hyphae or spores. A bacterial and fungal culture was performed on the sample taken from the middle portion of the nail, and P. aeruginosa was identified. A sensitivity test was also performed, and the organism showed sensitivity to a few antibiotic agents, including tobramycin. Hence, a diagnosis of pseudomonal green nail syndrome was established and tobramycin eye drop (3 mg/ml, Tobrex®; Alcon, Australia) was prescribed. Because there was a considerable crack between the nail bed and plate, we did not perform any kind of mechanical preparation such as nail grinding or resurfacing. The patient was instructed to apply the medication onto the area of nail separation that was located distally, twice a day. After 3 weeks, the pigmentation vanished and only the onycholysis remained (; photograph taken 8 weeks after treatment).

At 8 weeks after medication, the dark-green discoloration vanished and only a small part of the onycholysis remained.

DISCUSSION

Green nail syndrome (chromonychia) is a nail disorder characterized by greenish discoloration of the nail with onycholysis. The disease is occasionally accompanied by paronychia of the adjacent skin. P. aeruginosa is known as a causative organism^1,2,3. This organism is a gram-negative bacillus that can cause localized cutaneous infection to serious life-threatening systemic diseases⁴. Infections in healthy individuals are not usual. Sites of maceration, trauma, or foreign bodies in the skin may serve as portals of entry for the organism. Pseudomonas infection may produce characteristic cutaneous lesions involving the nails, toe webs, and hair follicles².

The green-black discoloration of the nail is due to pyocyanin, an antibiotic pigment produced by the Gram-negative P. aeruginosa. Like our patient, affected patients often have a history of long duration of exposure to water or moist conditions, providing an ideal condition for growth of P. aeruginosa, which is unable to colonize dry environments. Other predisposing factors are microtrauma, onychotillomania, and rarely, certain nail disorders such as psoriasis⁵.

Green nail syndrome may be treated singly or in combination with antiseptics, antibiotics, and sometimes, surgical removal of the involved nail. Antiseptics that can be used include chlorhexidine, 1% acetic acid, and 0.1% octenidine dihydrochloride solution^2,6, which show strong microbicidal activity against various bacteria including P. aeruginosa. However, the recommended practice of a few minutes of soaking several times a day may cause irritation of the affected skin and may lead to harmful effects or toxicity to the adjacent skin.

On the other hand, P. aeruginosa is naturally resistant to a wide range of antibiotics. In addition, it may develop additional resistance after an unsuccessful antibiotic treatment through the modification of porin. Therefore, antibiotic treatment should be initiated after a laboratory test for antibiotic sensitivity has been performed. Antibiotics that have activity against P. aeruginosa include aminoglycosides (gentamicin, amikacin, tobramycin), quinolones (ciprofloxacin, levofloxacin), certain cephalosporins (ceftazidime, cefepime, cefoperazone), carbapenems (imipenem, meropenem), antipseudomonal penicillins (piperacillin, ticarcillin), and others⁷. However, most of the antibiotics that have antipseudomonal activity are used intravenously. Of the oral medications available, ofloxacin is commonly used.

In infective nail diseases, topical therapy is desirable because it avoids the adverse effects associated with systemic therapy. However, systemic therapy is still the mainstay of treatment owing to the higher concentration of therapeutic agent in the lesion and the poor permeability of the nail plate to topically applied drugs^8,9. Various researches have been focused on improving transungual permeability by means of chemical treatment, penetration enhancers, and mechanical and physical methods⁹. In the present case, there were some obstacles in prescribing oral medication. First, on the basis of the sensitivity test result, ofloxacin, levofloxacin, and trimethoprim-sulfamethoxazole were the only medications taken orally. As mentioned above, the lesion showed no improvement despite the patient having taken 200 mg per day of levofloxacin for several weeks. Second, the patient was reluctant to take medications orally for the disease.

Tobramycin belongs to the aminoglycoside group of antibiotics, and it is indicated for the treatment of bacterial infections such as septicemia; meningitis; lower respiratory tract infection; intra-abdominal infection;and skin infection caused by P. aeruginosa, Klebsiella species, Enterobacter species, Escherichia coli, and other organisms¹⁰. It is available as an injection, nebulized solution, ophthalmic ointment, and solution. Treatment of the nail is challenging because the usual drug preparations sometimes could not reach the affected site. However, as the affected lesion functioned like a dead space and was a moist environment, we thought that the eye drop solution could easily percolate into the area of discoloration. Another consideration was the low concentration of the antibiotic agent in the eye drop (3 mg/ml). However, the outcome was satisfactory. The patient applied the eye drop twice a day without any inconvenience and had no adverse effect. We could attest that bacterial colonies may be effectively suppressed with low concentrations of the antibiotic agent. On the basis of our experience with the successful treatment of green nail syndrome by using tobramycin eye drop, we believe that tobramycin eye drop is a safe, welltolerated, effective therapeutic option for the treatment of green nail syndrome caused by P. aeruginosa.

Paronychia – an overview | ScienceDirect Topics

Discussion

Acute paronychia most commonly results from nail biting, finger sucking, aggressive manicuring, a hang nail, or penetrating trauma. Most infections are minor and can be treated easily with conservative methods. The more extensive the infection is, the more aggressive the surgical approach must be. Patients who have been adequately treated should be relatively asymptomatic within 3 to 5 days.

Ingrowing toenails (onychocryptosis) occur most frequently in the early to mid adolescent period. They tend to occur during periods of rapid foot growth when shoes get too tight. A precipitating event is usually cutting the nail at an angle to the sulcus. Subsequent growth causes a spicule of the nail, usually in the lateral sulcus, to penetrate the skin. This spicule introduces bacteria and infection into the surrounding tissue with formation of pus and granulation tissue.

Whenever conservative therapy is instituted, the patient should be advised of the advantages and disadvantages of that approach. If the patient is not willing or reliable enough to perform the required aftercare or cannot accept the potential treatment failure, it would seem prudent to begin with the more aggressive treatment modes.

No single antibiotic will provide complete coverage for the array of bacterial and fungal pathogens cultured from paronychias. Theoretically, clindamycin or amoxicillin plus clavulanate should be the most appropriate antibiotics, but because most paronychias are easily cured with simple drainage, systemic antibiotics are usually not indicated. In immunocompromised patients and those with peripheral vascular disease, cultures and antibiotics are indeed warranted.

Remain alert to the possible complications of neglected paronychia such as osteomyelitis, septic tenosynovitis of the flexor tendon, or a closed-space infection of the distal finger pad (felon). Recurrent infections may be due to a herpes simplex infection (herpetic whitlow) or fungus (onychomycosis). Tumors like squamous cell carcinoma or melanoma, cysts, syphilitic chancres, warts, or foreign body granulomas can occasionally mimic paronychia.

Failure to cure paronychia within 4 or 5 days should prompt specialized culture techniques, biopsy, or referral.

Paronychia Types and Causes

What is Paronychia?

Paronychia is a skin infection which occurs around the nail. It affects the nail fold tissue and may cause changes in nail shape, color or texture. The infection can be caused by a bacteria, fungi, or yeast.

There is also the possibility of both bacterial and fungal infection at the same time. It is fairly common and can cause the affected area to become swollen, red and painful. The infection may result in fluid-filled blisters over a period of time. Although the presence of blisters is not always registered. The condition is also called whitlow.

Paronychia, swollen finger with fingernail bed inflammation due to bacterial infection on a toddlers hand. – Image Copyright: zlikovec / Shutterstock

Types of Paronychia

There are primarily two types of paronychia which may develop around the finger or toenails. These are classified by the time duration that the skin infection lasts.

Acute Paronychia: The skin infection develops fast and lasts for a few days in acute paronychia. This kind of paronychia is seen following skin breaks during a manicure, or when infection sets into an ingrown toenail. It is usually bacterial in nature, often caused by straphylococcus aureus bacteria. However, germs from the cold sore virus like herpes simplex or yeast such as Candida may also cause the condition.

Chronic Paronychia: The infection develops slowly and may last for many weeks. In such cases, a mix of multiple pathogens causes the infection. A combination of yeast like candida, virus like herpes simplex, and bacteria like Staphylococcus aureus may be found. This condition is commonly found in people who have to work with their hands constantly being exposed to water, chemicals and detergents. It has a tendency to reoccur even after being treated and cured.

What Causes Paronychia?

Skin infections set in when there is an injury already present in the nail fold area. A break in the skin between the cuticle and the nail plate is an ideal place for pathogens to gather and infection to begin. People who have a habit of picking at the skin around the nail, or babies who suck thumbs and break the tender skin around the nail are quite likely to develop chronic paronychia.

People who have diabetes are more prone to skin infections in general and tend to get paronychia frequently. It takes them longer to heal from the infection than non-diabetics. Also, those who suffer from medical conditions that cause poor blood circulation are likely to get paronychia.

Certain occupations such as fishermen, dairy farmers, bartenders, and cleaners are predisposed to get paronychia. This is because their work exposes them to both a source of pathogens as well as a possibility of cuts on the skin. Women, especially homemakers, are affected more often than men. It is not hereditary.

Diagnosis and Prognosis of Paronychia

No special test is required to diagnose paronychia. A health care provider can usually identify the condition by a simple visual examination. If there is pus or fluid in the blister, it may be analyzed in the lab to check for the type of bacteria or fungus causing the infection. The outlook after diagnosis is fairly good for the disorder.

While fungal infections may take much longer to clear up, as treatment begins the pain is brought under control almost immediately. The tenderness of the skin also recedes. Acute paronychia will disappear within a matter of days. However since chronic paronychia takes longer to set in, it will take longer to heal. Even after chronic paronychia is cured, it may reoccur.

Treatment of Paronychia

The skin infection is treated with a combination of oral medication and local ointments. For acute paronychia caused by bacteria, oral antibiotics will be prescribed. If a blister is present, minor surgical intervention may be required. A local anesthetic is used to numb the area, and the health care professional will then lift the nail fold and cleanse the infected area.

The blister will be drained, and then a topical cream will be applied to fight the infection. It may be antibacterial or antifungal, based on the type of infection identified. In some cases, part of the nail may have to be removed if the blister is very deep rooted.

If there is no blister, the individual will be advised to soak their hands in warm water thrice a day, dry them properly, and apply the medicated ointment locally. Also, a skin-drying substance such as a skin paint, may be provided for professionals who are unable to avoid work conditions that cause paronychia.

Avoiding Paronychia

1. Don’t bite or pull at the edge of a nail.
2. Don’t suck on the thumb as it will make the skin tender and prone to breaks.
3. Don’t push the cuticles back during a manicure.
4. Ensure that all manicure tools are disinfected before using them on your nails.
5. Wear gloves when washing dishes or handling chemicals.
6. Keep your hands and feet clean and dry.
7. Cut your nails after bathing when they are softer.

References

Further Reading

How to drain a finger paronychia

What is a finger paronychia?

A paronychia is an infection of the nail root of the fingers or toes. It’s a very common infection and is caused by the introduction of bacteria under the cuticle. This is often from people chewing or ripping a hangnail with their teeth, and is also seen in barbers. 

In a wound culture, Staphylococcus is the most common bacteria. But, you can have any kind of bacteria (such as anaerobes) from the mouth. 

Physical signs of a finger paronychia

Patients usually seek help after a few days of increasing swelling and pain at the base of a nail. The area is sensitive and pressure from the building pus is painful.  

If the infection continues, it can extend to the pulp of the finger and cause a felon, or deep tissue abscess. This requires aggressive procedures and can even lead to loss of function or amputation.

^{Figure 1. Physical signs of a finger paronychia include swelling at the base of the nail, sensitivity to touch, pain, and pressure from pus build-up. A deep tissue abscess, or felon, can develop if the infection continues.} 

How do you treat paronychia?

If the infection is caught early when the nail base is a little swollen and red, you can prescribe frequent warm soaks (at least once every two hours), and a short course of antibiotics (e.g., cephalexin). An established infection and pus collection require incision and drainage. 

^{Figure 2. Early paronychia infections can be treated with frequent warm soaks and antibiotics. Established infections require incision and drainage.} 

The tools you need to drain a finger paronychia

The first step when performing the incision and drainage technique is to collect the necessary medication and tools:

• Sterilizing solution
• Ice water
• #11 scalpel

^{Figure 3. Tools for a finger paronychia include sterilizing solution, ice water, and #11 scalpel.} 

How to drain a finger paronychia

This step-by-step procedure ensures a safe, clean, and (relatively) painless abscess drainage:

1. Place the patient’s finger in a cup of ice water until they can’t stand it anymore to numb the finger. This method is fast, painless, and softens the cuticle. Alternatively, you can perform a digital nerve block. 
2. When the finger is numb, clean the cuticle with the sterilizing solution. 
3. Stab under the skin parallel to the nail, using your #11 blade. 
4. You will immediately see pus come out.  

^{Figure 4. Procedure for draining a finger paronychia. 1) Numb the finger with ice water or a digital nerve block. 2) Clean the cuticle with sterilizing solution. 3) Stab under the skin parallel to the nail with the #11 blade. 4) Pus will escape from the incision.}  

Post-procedure care for a finger paronychia

Have your patient soak their finger in warm water every two hours for the next two days. Antibiotics are not needed for minor cases of paronychia, but use your judgment depending on the patient’s risk factors. 

^{Figure 5. After draining a finger paronychia, instruct your patient to soak their finger in warm water every two hours for the next two days.} 

Excellent job! You’re well on your way to mastering the treatment of a finger paronychia. 

That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients. 

Green Nail Syndrome (Pseudomonas aeruginosa Nail Infection): Two Cases Successfully Treated with Topical Nadifloxacin, an Acne Medication – FullText – Case Reports in Dermatology 2014, Vol.

6, No. 2

Abstract

Green nail syndrome (GNS) caused by Pseudomonas aeruginosa is the most common bacterial nail infection. The treatment of GNS is challenging in many cases and recommendations based on clinical trials are lacking. We report two cases with GNS successfully treated with off-label use of topical nadifloxacin, a fluoroquinolone approved for acne and bacterial skin infections in some countries.

© 2014 S. Karger AG, Basel

Introduction

Pseudomonas aeruginosa is the most prevalent pathogen of bacterial nail infections [1]. Green nail syndrome (GNS) is characterized by greenish chromonychia caused by pyocyanin, a metabolite produced by P. aeruginosa. GNS is usually restricted to one or two nails [2,3]. Predisposing factors are onychomycoses, nail diseases, working in wet conditions, diabetes mellitus, paronychia and immunosuppression, among others [1,4,5]. P. aeruginosa can be transmitted from GNS to wounds or surgical sites [6,7] and thus lead to local and possibly systemic complications in immunocompromised individuals.

The treatment of GNS is challenging in many cases. Reported treatment options are systemic fluoroquinolones, topical octenidine 0.1% [2], topical aminoglycoside [5] and nail extraction [1,8]. Moreover, three patients with GNS successfully treated with topical nadifloxacin have been reported [3,4]. However, clinical trials of patients with GNS are currently lacking [1].

Nadifloxacin is a topical fluoroquinolone approved for the treatment of acne vulgaris in some countries (Germany, Italy, Spain, China, Japan and India, among others). It has a broad-spectrum activity against Gram-positive (including methicillin-resistant Staphylococcus aureus), Gram-negative and anaerobic bacteria. Hence in some countries (e.g. India, Japan) it is also approved for the treatment of skin infections.

Case Reports

Case 1

A 64-year-old otherwise healthy female developed an asymptomatic greenish discoloration of the nail plate of the right middle finger within 2 months. The discoloration started from the proximal nail plate and proceeded to the distal margin. There was no history of nail trauma or previous nail diseases. Treatment with topical acetic acid and ethyl lactate during 1 month showed no effect. At first visit a greenish discoloration and mild onychodystrophy of the entire nail plate with distal onycholysis exclusively on the right middle finger were observed (fig. 1). The cuticula was also discolored, but no signs of paronychia were present. Bacteriologic culture of nail scrapings was positive for P. aeruginosa. KOH preparation (direct mycological microscopy) of nail scrapings was negative, but the culture was positive for Candida parapsilosis. Nadifloxacin (Nadixa® cream) was applied once daily on the nail plate for 6 weeks. The coinfection with C. parapsilosis was treated with itraconazole 100 mg twice daily on weeks 1 and 5. The nail plate was cured within 6 months after the initiation of treatment (fig. 2).

Fig.

 1

Case 1. Coinfection with P. aeruginosa and C. parapsilosis. Presentation at first visit: greenish discoloration of the right middle finger.

Fig. 2

Case 1. Course after treatment with nadifloxacin once daily for 6 weeks and itraconazole 100 mg twice daily on weeks 1 and 5.

Case 2

A 49-year-old female with bulimia suffered from recurrent onycholysis of the big toes due to tight shoes. Moreover a yellow-greenish discoloration persisted for several weeks on the right big toe. Treatment with topical amorolfine once per week showed no response. Lateral yellow-greenish discoloration, distal onychodystrophy and onycholysis exclusively on the right big toe without signs of paronychia (fig. 3) were present at first visit. Bacteriologic culture of nail scrapings was positive for P. aeruginosa. Fungal coinfection was excluded by KOH preparation and culture. Nadifloxacin (Nadixa® cream) was applied once daily on the nail plate for 6 weeks. The nail plate was cured within 4 months after the initiation of treatment (fig. 4).

Fig. 3

Case 2. Infection with P. aeruginosa. Presentation at first visit: yellow-greenish discoloration, distal onychodystrophy and onycholysis on the right big toe.

Fig. 4

Case 2. Course after treatment with nadifloxacin once daily for 6 weeks.

Discussion

The clinical presentation of these two cases with P. aeruginosa nail infection in only one nail is typical. In both cases a predisposing factor was prevalent (onychomycosis in case 1, nail trauma in case 2). The observation of successful treatment with nadifloxacin is in line with previous reports [2,3,4]. Hence nadifloxacin might be an ‘easy-to-handle’, effective, nail-preserving and low-priced treatment option of GNS. As nadifloxacin is not approved for this indication, insurance confirmation of coverage should be provided.

Pseudomonas is not sensitive to itraconazole, hence the treatment effect on GNS in case 1 can be attributed to nadifloxacin. However, the treatment of the coinfection (C. parapsilosis) with itraconazole in this case contributed to the cure of the nail. Thus, screening for fungal coinfections and if needed antifungal treatment in patients with GNS is crucial.

Disclosure Statement

The authors declare no conflicts of interest.

References

1. 
   Nenoff P, Paasch U, Handrick W: Infections of finger and toe nails due to fungi and bacteria. Hautarzt 2014;65:337-348.
   




2. 
   Rigopoulos D, Rallis E, Gregoriou S, Larios G, Belyayeva Y, Gkouvi K, Katsambas A: Treatment of Pseudomonas nail infections with 0. 1% octenidine dihydrochloride solution. Dermatology 2009;218:67-68.
   




3. 
   Rallis E, Paparizos V, Flemetakis A, Katsambas A: Pseudomonas fingernail infection successfully treated with topical nadifloxacin in HIV-positive patients: report of two cases. AIDS 2010;24:1087-1088.
   




4. 
   Hengge UR, Bardeli V: Images in clinical medicine. Green nails. N Engl J Med 2009;360:1125.
   




5. 
   Tosti A, Piraccini BM: Nail disorders; in Bolognia JL, Jorizzo JL, Schaffner JV (eds): Dermatology, ed 3. Edinburgh, Elsevier, 2012, pp 1134-1135.
   




6. 
   McNeil SA, Nordstrom-Lerner L, Malani PN, Zervos M, Kauffman CA: Outbreak of sternal surgical site infections due to Pseudomonas aeruginosa traced to a scrub nurse with onychomycosis. Clin Infect Dis 2001;33:317-323.
   




7. 
   Mermel LA, McKay M, Dempsey J, Parenteau S: Pseudomonas surgical-site infections linked to a healthcare worker with onychomycosis. Infect Control Hosp Epidemiol 2003;24:749-752.
   




8. 
   Cho SB, Kim HS, Oh SH: Green nail syndrome associated with military footwear. Clin Exp Dermatol 2008;33:791-793.
   

Author Contacts

Simon Müller

Department of Dermatology, University Hospital Basel

Petersgraben 4, CH-4031 Basel (Switzerland)

E-Mail [email protected]

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Paronychia | Health | Patient

What is paronychia?

Paronychia is an infection of the skin just next to a nail (the nail fold). The infected nail fold looks swollen, inflamed and may be tender.

There may also be a small collection of pus in the swelling. The nail itself may become infected or damaged if a nail-fold infection is left untreated.

Paronychia is also sometimes called ‘whitlow’.

What causes nail-fold infections?

• Germs (bacteria). These tend to cause sudden-onset (acute) nail-fold infections which are painful. A bacterium called Staphylococcus aureus, which often lives harmlessly on our skin, is most often the cause.
• Candida. This is a yeast (a type of fungus) and is another common cause. Nail-fold infections with candida tend to develop slowly and cause persistent (chronic) infection. They do not cause pus to appear.
• Other germs (microbes). These include viruses and other fungi. They are less common causes.

Why do nail-fold infections develop?

Many nail-fold infections occur for no apparent reason. However, the following can increase the risk of germs (bacteria) and other germs getting into the nail-fold skin and causing infection.

Water

You are more likely to develop a nail-fold infection if your hands are in water for long periods, particularly with detergents. Some jobs involve having wet hands for long periods of time. Constant washing may damage the nail fold and allow infection to develop. The following are examples of people who might be more prone to nail-fold infections due to their job:

• Cleaners.
• Bartenders.
• Fishermen.
• Beauticians.
• People who wash dishes frequently.
• Dairy farmers.

Injury

A break in the skin allows the germs on the skin to get inside. Examples which make you more prone to infection around the nails include:

• Nail biting.
• Splinters.
• Poor manicure technique – for example, pushing the cuticles back too far with a hard instrument.
• Damaged or diseased nails or nail folds – for example, from skin conditions such as eczema or contact dermatitis.
• Ingrowing toe nails – the nail grows into the skin, breaking it.

Covering

If you use gloves for long periods, or use artificial nails, it can cause a moist, airless condition around your fingernails. This is good for some germs to thrive and cause infection.

What is the treatment for nail-fold infections?

Antibiotics

If your infection is caused by bacteria then an antibiotic may be prescribed. Antibiotics commonly used for this type of infection include flucloxacillin or erythromycin. In a minor infection an antibiotic cream may be all that is needed – for example, fusidic acid cream.

If the antibiotic prescribed is not improving your infection after you have been taking it for a few days, you should see your doctor. Your doctor may take a sample (swab) of the infected area (to determine the actual bacteria causing your symptoms). He or she may also change the antibiotic to a different one.

Draining the pus out

If a lot of pus has collected, and your finger or toe is very swollen, the pus may need to be drained. A small cut is made to allow the pus to come out.

Warm bathing and painkillers

It may also help to soak the affected finger in warm salted water four times a day. Painkillers, such as paracetamol or ibuprofen, often work well to ease any pain.

Treatment for paronychia which lasts more than six weeks

If the problem has dragged on for six weeks or more, it is called chronic paronychia. Chronic means persisting. If this is the case there may be an underlying skin condition. In other cases there can be infection with a yeast or fungus. This is particularly common in those people mentioned above who have their hands in water a lot.

Treatment options include:

• Keeping the hands warm and dry.
• Avoiding anything which might irritate the skin, such as soaps and detergents. Also avoiding injury, eg avoid manicures, finger sucking, nail biting etc.
• Wearing very comfortable shoes if the affected nail is a toenail, to avoid any pressure on it.
• Treating any underlying skin condition.
• Steroid creams, such as hydrocortisone or betamethasone.
• Antifungal creams such as clotrimazole, miconazole or terbinafine.
• Antifungal tablets such as terbinafine or itraconazole.
• An operation to open up the infected area, and keep it open and let it drain and heal over time.

What can I do to stop nail-fold infections from returning?

The following may help:

• Do not bite your nails or pick at the skin next to nails.
• Keep your hands and feet dry as much as possible. Dry well after washing.
• Wear rubber gloves (preferably cotton-lined) if you work a lot with water.
• Do not wear gloves or artificial nails for long periods.

Chloronychia: green nail syndrome caused by Pseudomonas aeruginos

¹Apollonia University, ²Nicolina Medical Center, Department of Dermatology, ³“P.Poni” Institute of Macromolecular Chemistry, Iasi, Romania; ⁴Department of Dermatology, 6th Military Support Unit, Ustka, Poland; ⁵Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania; ⁶Victor Babes University of Medicine and Pharmacy, Timisoara, Romania

Abstract: Green nails, also known as chloronychia or green nail syndrome, are characterized by green discoloration of the nail plate (greenish-yellow, greenish-brown, greenish-black), proximal chronic non-tender paronychia, and distolateral onycholysis. The cause is Pseudomonas aeruginosa infection of the nail plate in persons whose hands are constantly exposed to water, soaps, and detergents or are subject to mechanical trauma, especially in the elderly. Green or black coloration of the nails should raise suspicion for Pseudomonas infection and be treated with an oral quinolone (ciprofloxacin), particularly in aged patients. We present three cases of green nails in elderly persons.

Case series

Case 1

A 67-year-old healthy retired man developed an asymptomatic greenish discoloration of the nail plate of the right toe nail over a period of 2 months. There was a history of chronic nail trauma prior to the discoloration, probably due to tight shoes. Dermatologic examination showed greenish-black discoloration, mild onychodystrophy of the entire nail plate, and distal onycholysis (Figure 1).

Bacteriologic culture of nail scrapings was positive for Pseudomonas aeruginosa. Fungal coinfection was excluded by potassium hydroxide preparation and culture. The nail plate was cured after 6 weeks of oral ciprofloxacin.

Case 2

A 68-year-old gardener was seen during summer, after working in wet conditions, for green discoloration of his right finger nail, slight pruritus, and pain. On clinical examination, distal onycholysis and greenish discoloration were noticed on the nail plate starting from the distal edge (Figure 2).

Bacteriologic culture of nail scrapings was positive for P. aeruginosa. No fungal coinfection was proved. Cutting the distal part of the nail plate and application of topical gentamicin twice daily for 1 month were followed by positive results.

Case 3

A 56-year-old man, diagnosed 1 year earlier with toenail onychomycosis, in the absence of any treatment, developed greenish discoloration of the entire nail plate. No signs of paronychia were noticed, only subungual hyperkeratosis (Figure 3).

Bacteriologic culture of nail scrapings was positive for P. aeruginosa. Direct mycologic examination of nail scrapings was positive and culture was positive for Trichophyton rubrum. The fungal infection was treated with itraconazole 200 mg/day 14 days per month for 3 months. Bacterial infection was cured after systemic administration of ciprofloxacin 500 mg/day for 3 weeks.

Discussion

Bacterial infections of the nails are caused by Gram-negative bacteria, usually P. aeruginosa, but can also be caused by Klebsiella spp. and Gram-positive bacteria like Staphylococcus aureus.^1,2P. aeruginosa is the most common pathogen causing bacterial nail infections, although it is rarely reported.³P. aeruginosa is a Gram-negative, aerobic, coccobacillus belonging to the Pseudomonadaceae family. These pathogens are widespread in nature, inhabiting soil, water, plants, and animals (including humans).

More than half of all clinical isolates produce the blue-green pigments pyoverdin and pyocyanin.²P. aeruginosa is an opportunistic human pathogen that can produce pulmonary, kidney, and urinary tract infections and even systemic infections. It can be also involved in soft tissue infections, skin and nail infections in immunocompetent subjects and patients with immune deficiency syndrome. P. aeruginosa is not part of normal skin flora, so Pseudomonas infections of the intact nail are rare. When infection occurs, P. aeruginosa colonizes moist regions of the skin, axillae, anogenital regions, and retroauricular areas.

The pathogenesis of nail infections caused by P. aeruginosa is not fully elucidated. Predisposing factors must be taken into consideration: onycholysis, onychotillomania, microtrauma to the nail-fold, chronic paronychia, chronic exposure to water, soaps, or detergents, and associated nail disorders, such as psoriasis.⁴

Onycholysis is characterized by separation of the nail plate from the nail bed; it is followed by secondary Pseudomonas infection, particularly when the nails are exposed to a warm and moist environment. A number of triggers for onycholysis have been reported, including psoriasis, onychomycosis, yellow nail syndrome, contact dermatitis, medications (doxycycline), endocrine disorders (acquired hypoparathyroidism),⁵ constant local trauma, especially in elderly. Chloronychia is more common in homemakers, barbers, dishwashers, bakers, and medical personnel, and can be regarded as an occupationally triggered disease.⁶

Small cuttings from the affected nail and/or subungual debris should be sent to the laboratory for investigations. Gram stain coloration is performed presenting Gram-negative rods with no particular arrangement; on cetrimide agar medium, P. aeruginosa expresses pyocyanin, a blue-green exopigment, and the colonies are flat, large, and oval, with a characteristic fruity smell.

Recently it has been reported a strong relation between fungal and P Aeruginosa infection of the nail: fungal infection stimulates bacterial colonization within the nail and overgrowth of P Aeruginosa in culture inhibits the isolation of fungus.⁷ The differential diagnosis includes subungal hematoma, malignant melanoma, infections caused by other pathogens such as Aspergillus, Candida, and Proteus, and chemical exposure to solutions containing pyocyanin or pyoverdine.⁸

The treatment of chloronychia, especially in elderly people, is difficult in many cases and recommendations based on clinical trials are missing.³ In the past, removal of the entire nail was a therapeutic option, but not nowadays. Treatment consists of cutting off the detached nail plate, brushing the nail bed with a 2% sodium hypochlorite solution twice daily, prevention of repeated immersion by wearing cotton and latex gloves and antibiotics administered topically and orally.

Topical silver sulfadiazine, ciprofloxacin, and gentamicin have also been reported to be valuable therapeutic options.⁹ Topical antibiotics (polymyxin B or bacitracin) applied 2–4 times daily for 1–4 months have been demonstrated to be effective in immunocompetent patients.⁶ Topical therapy with nadifloxacin applied once daily for several weeks was curative for two patients with acquired immune deficiency syndrome.⁴ When topical therapies are not preferred by the patient, oral ciprofloxacin should be recommended for 2–3 weeks.

Pseudomonas infections of the nails are treated by fluoroquinolones, when necessary, in comparison with other bacterial nail infections that require culture and sensitivity testing. This is the reason to recognize easily, by simple clinical observation of the color of the nails, especially in aged persons, to avoid unnecessary laboratory investigations and to save time.

Conclusion

Green coloration of the nails should raise suspicion for Pseudomonas infection. Treatment with an oral quinolone (ciprofloxacin), particularly in aged patients when laboratory investigations are difficult to perform, could be a valuable option.

Disclosure

The authors report no conflicts of interest in this work.

References

90,000 fingers are in danger / News of the Society of Krasnoyarsk and Krasnoyarsk Territory / Newslab.Ru

There are many diseases that can lead to hospitalization in a surgical hospital. There, among the patients, bedridden after severe operations and injuries, one can meet very healthy-looking patients, the only symptom of an ailment in whom is … a bandaged finger on their hand. What kind of disease is this, in which the defeat of only one finger (usually the thumb, index or middle) can lead to disability, and in rare cases – even threaten a person’s life?

Panaritium (aka the popular nail or hair eater) is an acute purulent inflammation of the tissues of the fingers.The disease begins with the banal penetration of the infection under the skin: through a small cut, a wound left after a torn barb, a splinter, a bite or a scratch. The risk of “earning” felon is greater for those who work in the workplace (occupational injury), but potentially any person, regardless of gender, age and occupation, can develop this disease.

The fact that purulent inflammation of the finger is a very dangerous condition is explained by the peculiarities of the anatomical structure: on this small part of the body there are many functionally important formations (tendons, tendon sheaths, blood vessels, nerves, muscles, joints).The subcutaneous fat on the palmar surface of the finger has a lobular structure: the connective tissue connects the skin of the finger with the periosteum of the phalanx. This contributes, on the one hand, to the delimitation of the inflammatory process along the finger, on the other hand, to its spread deep into the periosteum, to the tendons and joints.

Depending on the “epicenter” of inflammation, panaritiums are divided into cutaneous, periungual, subungual, subcutaneous, bone, articular and tendon. With the progression of the process, all anatomical formations of the finger can become inflamed, and then panaritium will be called “pandactylitis”.

The main symptom of the developing panaritium is “twitching” pain, usually most pronounced in the center of the purulent focus, especially if it is located on the palmar surface of the finger, where the tissues are dense and abundantly supplied with nerve endings. The intensity of pain depends on the stage of the inflammatory process; it is aggravated by finger movement and may even deprive you of sleep. There is always an increase in temperature over the site of inflammation and edema, as a rule, is more pronounced on the dorsum of the finger.Redness of the skin is usually mild. The function of the finger and hand is impaired.

The danger of panaritium is that in the absence of the necessary treatment, the process can move from one formation to another, up to damage to the lymphatic vessels of the finger, through which the infection can spread outside the hand and lead to general inflammation and even sepsis. In less serious cases, persistent dysfunction of the finger, up to irreversible, is possible – for example, with purulent fusion of the bones of the phalanges or deformation of the joints between them.

It is precisely because of the seeming “frivolity” of the problem that patients often postpone a visit to the doctor until the last, while the aggravation of the process affects the prognosis of treatment. And if in the early stages of panaritium therapy consists in the imposition of semi-alcohol dressings, physiotherapy and the appointment of antibiotics, then in the event of complications, an operation is required. It consists in opening a purulent focus, cleaning the wound and installing rubber drains, through which pus will subsequently come out.If the tissue around the nail is involved in the inflammation, it may be removed. In severe cases (for example, with complicated pandactylitis), the finger is sometimes amputated.

It is very important to consult a doctor in a timely manner (in case of intense pain, which sometimes interferes with night sleep, or better yet earlier). You cannot treat felon with “home” means and methods, for example, by piercing the wall of a purulent bladder visible under the skin. If the inflammatory process is located deeply, the opening of the so-called “cufflink abscess” does not lead to the elimination of the infection, but only complicates the process.Moreover, attempts to self-medicate with such means as ointments, warming compresses, etc. are unacceptable.

Thus, the smallest finger injury can turn into serious troubles. You can avoid them without forgetting about the elementary rules: disinfection of the wound surface with iodine or brilliant green, applying a bactericidal plaster, careful hand hygiene and using only your own manicure tools.

Olga Darsavelidze

Abscess, Incision And Drainage

An abscess (sometimes called an “abscess”) occurs when bacteria enter the skin and begin to multiply.Pus forms in the abscess cavity, as the body reacts to the presence of bacteria. An abscess can be associated with an insect bite, ingrown hair, a blockage of the sebaceous gland, acne, cysts, or puncture wounds.

Your abscess required an incision to remove pus. If the abscess cavity is large, then a gauze pad could be inserted. At the next visit, this tampon will need to be removed and possibly replaced with a different one. When treating a simple abscess, antibiotics are not required unless the infection has spread to the skin around the wound (called cellulitis).

The wound will take approximately one to two weeks to heal, depending on the size of the abscess. Healthy tissue will grow from the bottom and edges of the wound until the wound heals.

Home Care

1. During the first two days, fluid may leak from the wound. Cover the wound with a clean, dry dressing. If the dressing becomes soaked in blood or pus, change it.

2. If a gauze swab was inserted into the abscess cavity, then you may have been advised to remove it yourself.This can be done in the shower. After removing the tampon, it is necessary to wash the abscess area under the shower or in the bath 3-4 times a day until the wound heals.

3. If you are prescribed antibiotics, take them as directed by your doctor until they run out.

4. Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) can be taken to reduce pain if no other pain relievers have been prescribed. [ NOTE. If you have liver disease or a history of stomach ulcers, consult your doctor before taking these medications.]

See a doctor for FOLLOW-UP as directed by our staff. If a gauze swab was inserted into the wound cavity, it must be removed after 1-2 days. Examine the wound every day for signs of worsening infection, which are listed below.

Get Immediate Medical Assistance

for any of the following:

• increased redness or swelling;

• red stripes on the skin radiating from the wound;

• increasing pain or swelling in the wound area;

• continued discharge of pus two days after opening the abscess;

• At a temperature of 100.4єF (38єC) or higher, or as directed by a healthcare practitioner.

Panaritium: take care of children’s fingers – Letidor

How it is treated

At the initial stages of the development of the infectious process, conservative treatment is possible, for example, in the form of antibacterial therapy, baths with hypertonic salt solution and physiotherapy. Unfortunately, it is often this stage of inflammation that parents skip and do not seek help.

Usually felon is treated with antibiotics and special ointments.If the abscess is already ripe, the surgeon opens it, after which the baby is prescribed a course of antibiotics to kill the infection completely and prevent it from spreading to new tissues. The operation is performed under local anesthesia in sterile conditions. The surgeon opens the purulent focus, evacuates the contents, while sending it to the laboratory for sowing. Then the wound is washed with antiseptics, drainage is placed for 1-2 days and a sterile ointment bandage is applied. Further, daily dressings and, of course, medical supervision are required.

I would like to warn parents against treating panaritium at home on their own – with folk remedies, compresses and antibiotics. If you suspect an infection, you need to immediately see a doctor who will assess the degree of the disease and prescribe a plan for further action. If you notice the disease in the initial stages, then surgical intervention can be avoided. But if you self-medicate, open up abscesses on your own and give your child antibiotics, this can cause a lot of complications.The infection runs the risk of invading the joints and causing purulent arthritis, which can subsequently lead to loss of motor ability and lead to disability. It can also enter the bloodstream and affect the functioning of internal organs. And thoughtless intake of antibiotics will lead to the fact that the infection will become completely insensitive to this group of drugs.

As a preventive measure

Of course, it is better not to allow felon at all. For prevention, you need to ensure that even minor injuries are treated as soon as possible.

When going with your child to the playground, be sure to take with you an antiseptic gel, antibacterial wipes or iodine in a pencil, an antibacterial plaster, so that even the smallest wound can be quickly treated if necessary.

Teach your child to wash their hands every time they interact with the environment, be it walking outside or playing with a cat.

Gently trim your child’s nails and hangnails. If you accidentally inflict a microtrauma, treat the cut immediately.

Preparations Akriderm – cream and ointment for the treatment of dermatitis, skin allergies in adults

1. Instructions for medical use Akriderm ^® GK.

2.According to the data of the independent retail audit company of IQVIA pharmacies, among topical steroids containing a combination of “hormone + antibiotic + antifungal agent”, in terms of 1 g for the period January-March 2021

3. Efficiency and tolerance of the “line” Akriderm ^® in the practice of a dermatovenerologist, Matushevskaya E.V., Shakurov I.G., Khismatullina Z.R., Klin. derm. and venerol., 2008, No. 2, pp. 12-17

– Efficiency and safety of using Akriderm ^® GK cream in children with allergic dermatitis, Lyan N.A., Kornacheva L.A., Cheburkin A.A.,

– Experience in the use of Akriderm ^® in the complex therapy of patients with chronic dermatoses, Chigodaikin G.P., Kovaleva Zh.V., Neminuschiy Yu.G., Beketov A.M., Topical issues of dermatovenerology: materials of the XVI regional scientific and practical conference dedicated to the 110th anniversary of Professor I.I., Krasnoyarsk, 2006, pp. 134-135

– Clinical and immunological parameters in patients with atopic dermatitis treated with drugs of the line Akriderm ^® , Ertneeva I.Ya., Matushevskaya E.V., Svirshchevskaya E.V., Clinical Dermatology and Venereology, 2008, No. 5, P. 35- 39

4.Glucocorticosteroids for topical use in a modern strategy for the treatment of inflammatory dermatoses in pediatric practice. Batyrshina S.V. 09 (14) Practical Medicine.2014: 30-35

5. Patent No. 2223097, Patent No. 2325912

6. Topical hormonal drugs – drugs of first choice for the treatment of dermatitis. Federal clinical guidelines for the management of patients with atopic dermatitis, eczema. 2015 year.

7. Redness, itching, inflammation, infection in the following diseases: simple and allergic dermatitis (especially complicated by secondary infection), diffuse neurodermatitis (including atopic dermatitis), limited neurodermatitis (incl.including simple chronic lichen), eczema, dermatomycosis (dermatophytosis, candidiasis, versicolor versicolor). According to the instruction Akriderm GK

8. Instructions for medical use Akriderm ^®

9. Khardikova S.A. Rational choice of a combined topical glucocorticosteroid in an outpatient appointment with a dermatovenerologist // Clinical Dermatology and Venereology, 2018. No. 2. S. 67-72.

10. Simple and allergic dermatitis (especially complicated by secondary infection), diffuse neurodermatitis (incl.including atopic dermatitis), limited neurodermatitis (including simple chronic lichen), eczema, dermatomycosis (dermatophytosis, candidiasis, versicolor versicolor), especially when localized in the groin and large folds of the skin.

Nail pathology is an indicator of general or skin diseases. Part 2

Variants of nail color change and their reasons are discussed. Particular attention is paid to the lesion of nails in skin diseases with the presentation of their own observations of the pathology of the nails in patients with psoriasis, lichen planus, eczema, pityriasis pityriasis Deverji, follicular vegetative dyskeratosis Darier-White, diffuse and focal alopecia, acantholytic pemphigus, onychomycosis.The illustrations of individual onychodystrophies in dermatological patients are presented.

Nail discoloration
Nail discoloration can be caused by abnormalities of the nail plate itself, abnormalities of the nail plate-nail bed connection and nail bed abnormalities [I]. The color of the nails can range from white, yellowish, brown, orange to red, blue, green and black. Discoloration of nails can be congenital, hereditary and acquired. All nail color changes are divided into primary and secondary [2, 3, 4].Changes in the color of the nail bed and nail may be due to the accumulation of melanin, hemosiderin and other pigments [1, 5, 6].

Primary dyschromias are rare, mainly in people with dark skin. A nevus localized in the matrix can be the cause of the appearance of strip-like pigmentation along the entire length of the nail plate [5]. Brown longitudinal stripes on the nails are found in women in menopause, with hormonal dysfunctions and diabetes, after gynecological operations.Brown nails in the white race can be observed in primary adrenal insufficiency and Nelson’s syndrome [5]. In patients with psoriasis, longitudinal subungual hemorrhages were observed in the distal third of the nail, at first they have a plum color, and after a few days the color of these stripes changes to brown or black [7].
Secondary discoloration of the nails is more common. It has been noted that in some cases a transparent nail plate makes it possible to observe a change in the color of the nail bed [2, 3].

IG Shimanskaya notes that the livid color of nails can be observed in cardiac patients, pale pink nails – with anemia, white-gray – with cirrhosis of the liver, yellow – with jaundice [2]. Cyanosis of the nail bed is observed with decompensated mitral valve defects, liver cirrhosis, and peripheral spastic conditions [1, 3]. Black nails are characteristic of diabetic gangrene, with brachial artery thrombosis. The appearance of melanin pigmentation of nails (total or strip-like) can be caused by the use of cytotoxic drugs, HIV infection, endocrinopathies, Langer’s disease, Peutz-Jigers syndrome, or be the result of trauma, the use of certain drugs (silver nitrate, dithranol, potassium permanganate), contact with tobacco , electron beam therapy [1, 6, 8].The defeat of the nail plate with Pseudomonas aeruginosa is accompanied by staining of the nail in green, with the defeat of Aspergillus nails, depending on the type of Aspergillus, can be painted yellow, brown or black [1, 6, 9]. With candidiasis, a brownish-greenish color of the nails was sometimes observed. Nails look gray before and during an attack of malaria. When bilirubin and its metabolic products are deposited in the nail plate in patients with liver cirrhosis, the nails change color to yellow-brown.Bluish staining of nails is sometimes recorded with prolonged use of antimalarial drugs, phenothiazides and in dermatological patients who used copper sulfate solutions [6].

Yellow nail syndrome is characterized by three symptoms: yellow nails, emphysema and respiratory tract damage, the entire nail plate changes color from pale yellow to dark yellow-green. The greatest pigmentation at the edges of the nails, and the nails themselves thicken and coarse, their growth slows down [1, 4, 6].With lichen planus, an imitation of yellow nail syndrome can be observed [1, 9-11]. Yellowing of nails has also been described after treatment with phenytoin and lithium salts [1].

Leukonychia is manifested by the appearance in the thickness of the nail plate of white areas of different sizes and shapes, they can be congenital or acquired [1, 3, 5, 6]. Leukonychiae are total, subtotal, punctate and striped (matte white spots or stripes). Point leukonychias appear after manicure injuries.On one nail plate, you can see both the last variants of leukonychia. In striped and punctate leukonychia, white spots and stripes move distally as the nail grows. In their pathogenesis, a certain value is assigned to injuries and infectious diseases suffered due to a violation of the trophism of the nail. All clinical forms of leukonychia, except for spotty, can be congenital [6].

Mürke’s lines are two white stripes parallel to the nail hole, which do not shift during its growth, which indicate the presence of hypoalbuminemia, especially in nephrotic syndrome (restoration of normal serum albumin values ​​leads to their disappearance) [3, 5].

The lines of Mürke are separated from each other and from the lune by pink stripes [13]. They can appear after trauma, with a low level of albumin in the blood, with the use of cytostatics [1].

Bicolor nail or Terry’s symptom. This onychodystrophy is characterized by the fact that the proximal 2/3 of the nail is white, and the distal 1/3 is pink. It is observed in some patients with heart failure, uremia, liver cirrhosis against the background of hypoalbuminemia, with non-insulin dependent diabetes mellitus [1, 3-5, 12].

A number of medications, when taken for a long time, can affect the color of nails. Akrikhin paints the nail bed yellow. External use of resorcinol can provoke orange color of nails, ointments with cytostatics – black. Antimalarial drugs can stain (atebrine) a yellowish green or bluish black (resoquin) color. Cyanotic nails with a greenish tinge were observed in cases of poisoning with copper salts, treatment with cytostatics or DDS [1, 2].

It is necessary to dwell on the subungual localization of melanoma, which accounts for 1-4% of all cases of melanoma in people with fair skin and up to 25% with dark skin.

This is acral-lentiginous melanoma, localized in the nail bed more often than the big toes. This form of melanoma is not preceded by nevi. In the early stages of melanoma, only a brown elongated line on the nail is visible in the area of ​​the nail bed or matrix. The tumor begins to palpate only when melanoma enters the stage of vertical growth [14].As a result, the nail plate is lifted by a growing tumor, pain appears, an increase and increase in the area of ​​pigmentation, longitudinal splitting and degeneration of the nail (Fig. 1, color insert). Hutchinson’s syndrome is considered pathognomonic – the spread of black-brown pigmentation to the posterior and lateral nail folds, to the cuticle, as well as to the entire nail bed and nail plate [2, 3, 5, 14].

Subungual hematoma may result from a single acute trauma or multiple microtraumas.In hematoma, the darkened pigmented area is limited to the nail bed, persists for 2-3 months and slowly moves distally as the nail grows.

Nail damage in skin diseases

Psoriasis. According to R. Baran and E. Haneke, in 30-50% of patients with psoriasis, nails are involved in the pathological process at one stage or another of the disease [1]. According to other authors, nail changes in psoriasis are detected in 10.0-87.7% of patients, while not all patients have a pronounced skin process [3, 6, 15].In psoriasis, pathological changes can affect almost all structures of the nail, manifesting themselves in various clinical forms of nail damage (Fig. 2-6, color insert).

The most common are punctate depressions (thimble symptom) and striation of the nail. Psoriasis of nails is characterized by rounded depressions with a diameter of 1-1.5 mm, their number is different – from several dimples to 10 or more, can cover the entire surface of the nail (see Fig. 4, color insert). It is believed that psoriatic depressions arise from tiny psoriatic papules in the proximal matrix, which is responsible for the formation of the dorsal nail plate [1].It has been proven that the thimble-like depression is not a true depression, but a defect in the substance of the nail plate (psoriatic erosion). Individual depressions on the nail plate can be located longitudinally or transversely, which indicates more extensive lesions of the matrix [1, 16]. Of other onychodystrophies in psoriasis, onycholysis of the distal part of the nail, oil spots (see Fig. 5, color insert), subungual hemorrhages, longitudinal stripes, thickening of the nail, fragility, the appearance of scallops, subungual hyperkeratosis, leukonychia in the form of smoky paronychia, psoriatic and onychomadesis [1, 3, 6, 15].At the same time, none of the clinical manifestations of nail damage is strictly pathognomonic for psoriasis. M.M. Reznikova et al. examined 476 patients with psoriasis aged 18 to 70 years, 40% of them had changes in the nail plates, microscopic examination revealed onychomycosis in 119 patients of this group [17].

When examining nails in 68 patients with psoriasis, in 13 of them, we revealed onychodystrophies, including: thimble-like stitching of the nail – in 5; trachyonychia – in 2; distal onycholysis – in 2, one of the patients also had strip-like leukonychia on the II and IV fingers of the right hand; subungual hyperkeratosis and increased nail fragility – in 2; hemorrhagic spots visible through the nail – in 1 patient.In 1 patient, psoriatic paronychia was observed on 6 fingers of the hands with pronounced lamellar peeling of the posterior nail fold and striped leukonychia. The experience of psoriatic disease in all patients was more than 10-15 years.

In addition, 5 patients were diagnosed with onychomycosis of the feet with pronounced subungual hyperkeratosis, and in 2 all 10 nail plates of the feet were affected.

Lichen planus. Among 21 patients with lichen planus, nail pathology was detected in 6.Severe brachyonychia occurred in 2 patients, onychochisis was detected in 1 patient; the presence of ribbing, longitudinal grooves and ridges on the surface of the nails of the I-III fingers of the hands was noted in 1 patient.

Onychorexis (splitting of nails in the longitudinal direction) on 2 fingers of the right hand was observed in 1 patient, appeared in the 2nd year of the disease. The presence of trachyonychia in the proximal part of the nail of the index finger of the right hand in combination with distal onycholysis was noted in a 48-year-old patient with about 2 years of experience with lichen planus.

According to the literature, the pathology of the nails with lichen planus is very diverse. Longitudinal grooves are more common, alternating with longitudinal ridges on the surface of the nail plate, which loses its shine and becomes dull [1, 6]. The distal edge of the nail may exfoliate, small particles of the nail fall off, forming defects [3]. Many patients had point dystrophy, onychochisis, koilonychia in the distal part of the nail plate, and nail dystrophy can sometimes lead to anonychia [1].

Damage to nails with eczema. Eczema of the hands and / or feet is often accompanied by onychodystrophies and painful paronychias. Nail involvement usually begins at the proximal margin. The surface of the affected nail becomes rough, dull, flaky, longitudinal grooves appear, the nails become yellowish-gray. The nail skin (eronychium) may disappear. When the nail bed is involved, patients with eczema may develop subungual hyperkeratosis, and a thimble symptom appears on the surface of the nail [1, 6].According to R. Baron and E. Haneke, depressions (trachyonychia) are a characteristic sign of nail eczema, which does not depend on the type of eczema [1]. They are usually shallow and can appear in large numbers. In severe eczema, onycholysis can be observed (Fig. 7, color insert) and even complete rejection of the nail plate, as in Lyell’s syndrome. In patients with atopic dermatitis and limited neurodermatitis, the nails look like polished, due to scratching of the itchy skin with the dorsal part of the distal phalanges of the fingers.Mycological examination of patients with eczema revealed that 36.2% of eczematous onychiae were complicated by onychomycosis; T. interdigitale cultures were isolated in 25.6%, and T. rubrum in 4.6% [18].

Of the 28 patients we examined, suffering from chronic eczema of the hands, 6 patients had nail changes. They started from the proximal edge of the nail plate, while in 2 patients the nails were dull and rough (trachyonychia), in 2 patients with onychauxis (thickening of the edge of the nail with pronounced subungual hyperkeratosis).Onychomycosis on the toes was detected and mycologically confirmed in 2 patients with eczema, and in 1 patient, onychodystrophy of the nail plates on the hands (trachyonychia) was simultaneously observed.

Follicular vegetative dyskeratosis (Darier-White disease). With Darier-White’s disease, wedge-shaped subungual hyperkeratosis is often strongly expressed. It can be combined with longitudinal white and reddish lines ending in V-shaped notches on the free edge of the nail [1].

Among 17 patients with follicular vegetative dyskeratosis (Darrieus-White disease), 5 patients were found to have changes in the nails, in 3 of them it was about the appearance of leukonychia in the form of white longitudinal stripes, the distal edge of the nails was broken off unevenly.In 2 patients, along with the presence of weakly expressed longitudinal stripes, there were punctate depressions and moderately pronounced subungual hyperkeratosis.

Deverji pityriasis pityriasis. The disease is quite often manifested by thickening of the nails, their staining in gray, the appearance of grooves and pronounced subungual hyperkeratosis [1]. American authors note that the more active the rash on the dorsal surface of the fingers, the more pronounced the pathology of the nails [19].

We observed 24 patients with pityriasis pityriasis Deverji, who consulted in 2012-2015. Nail pathology was detected in 8 patients, including onychorexis was observed in 2, thimble-like stitching of the nails – in 3. Another 3 young men had hyperkeratosis of the distal nail bed with thickening of the nail plate and single small subungual hemorrhages.
Lesions of nails in focal and diffuse alopecia. There are reports that in 46% of patients with alopecia areata, nail pathology is observed.At the same time, point depressions and longitudinal striation of the nail surface, undulating irregularities and onychorexis were noted [3]. There may be signs of micronychia due to the habit of constantly biting your nails. According to OV Molchanova, out of 60 patients with diffuse alopecia, onychodystrophies were found in 30 [20]. The assessment of the condition of the nail plates in this study was carried out using the NAPSI (Nail Psoriasis Severity Index) index for the following pathological signs: increased fragility of the nail plates, delamination along the free edge, longitudinal grooves, transverse grooves, leukonychia.Damage to nails with universal alopecia is much more common than with focal alopecia, and the more severe alopecia is, the more often nails are involved in the process [1, 21].

In 2012—2015 68 patients with alopecia areata (multifocal alopecia of the scalp in 59 people, subtotal alopecia – in 9) applied for a consultative appointment. Onychodystrophies were diagnosed in 26, and the typical signs of micronychia due to constant nail biting (mainly children and adolescents aged 6-15 years) were in 7.Of the other manifestations of onychodystrophies, onychorexis, nail hyperkeratosis, longitudinal grooves of the nails, distal onycholysis, and 2 cases of thimble-like stitching of the nail surface were more often detected.

Acantholytic pemphigus can be the cause of nail damage and even their complete loss. The results of examination of 64 patients with pemphigus vulgaris are reported; nail changes were found in almost half of them [22]. Subacute and chronic paronychia, trachyonychia, Bo – Reilly lines, deep transverse grooves, onychomadesis were observed.Rejection of the nail with pemphigus vulgaris is possible only with a primary lesion of the nail bed. In Lever’s bullous pemphigoid, transverse lines were observed, but complete nail loss is also possible [1].

In congenital epidermolysis bullosa, nail dystrophy is very characteristic, especially in dystrophic form. It can end with scarring of the nail area and complete anonychia [1].

Fungal nail infections (onychomycosis). The causative agents of onychomycosis are dermatophytes (80–94% of cases), yeasts and molds [23, 24].Depending on the area of ​​the nail lesion, there are distal, lateral and proximal forms of onychomycosis. IG Shimanskaya notes that distal onychomycosis can occur with significant total thickening of the nail and pronounced subungual hyperkeratosis (onyhauxis) or with the separation of the distal part of the nail from the bed by the type of distal onycholysis [2]. Lateral onychomycosis is manifested more often by subungual hyperkeratosis and lateral onycholysis (Fig. 8, color insert).

Proximal onychomycosis begins in the area of ​​the lune and posterior nail fold.They also describe white superficial onychomycosis, in which white islands appear on the surface of the affected nails of the foot, and more often only the dorsal surface of the nail plate is affected. By the nature of nail damage, hypertrophic (up to onychogryphosis), normotrophic and atrophic (onycholytic) types of onychomycosis are distinguished [24].

Contact information:
Pankratov Oleg Valentinovich – Doctor of Medical Sciences, Professor, Head. Department of Dermatovenereology and Cosmetology.Belarusian Medical Academy of Postgraduate Education.
220013, Minsk, st. Prilukskaya, 46a; sl. Tel. (8-017) 372-74-40. Participation of the authors:
Concept and design of the study: O. V. P, R. Yu. Sh., V. G. P. Collection and processing of material: O. V. P., R. Yu. Sh., V. G . P. Statistical data processing: O. V. P., R. Yu. Sh., V. G. P. Text writing: O. V. P., R. Yu. Sh., V. G. P. Editing: O. V. P., V. G. P., R. Yu. Sh. No conflict of interest.

LI T E R A T U R A
1.Baran R., Haneke E. Differential diagnosis of nail damage: Atlas. / Per. from English I. V. Harmandaryan; ed. V. Yu. Vasenova. M .: GEOTAR-Media; 2011.200 s.
2. Shimanskaya IG Diseases of the nails: Teaching aid. Minsk: BelMAPO; 2008.34 p.
3. Shikalov R. Yu., Pankratov O. V. Onychodistrophies: a training manual. Minsk: BelMAPO; 2010.43 p.
4. Mertsalova IB Onychodystrophy. Therapist. 2010; 5: 32-3.
5. Tsykin A. A. Onychodistrophies: clinical picture, diagnosis, treatment.Breast cancer. 201S; 9: 508-13.
6. Vasenova V., Butov Yu. Modern view of onychodystrophy (part II). Aesthetic medicine. 2012. Volume XI, 4: S99-606.
7. Scher R. K., Daniel R. Nails: Therapy, Diagnosis, Surgery. Philadelphia: WB Saunders; 1990.113 p.
8. Quinlan K. E., Janiga J. J., Baran R., et al. Transverse melanonychia secondary to total skin electron beam therapy: a report of 3 cases. J. Amer. Acad. Dermatol. 200S; 1S (1): 112-4.
9. Chernosky M., Dukes D. Green Nails.Arch. Dermatol. 1963; 88: 548-53.
10. Tosti A., Piraccini B.M., Gamel N. Nail changes in lichen planus may resemble those of yellow nail syndrome. Brit. J. Dermatol. 2000; 142: 848-9.
11. Baran R. Lichen planus of the nails mimicking the yellow nail syndrome. Brit. J. Dermatol. 2000; 143: 1117-8.
12. Lindsay P. G. The half-and-half nail. Arch. Intern. Med. 1967; 119: 583
13. Muehrcke R. C. The fingernails in chronic hypoalbuminemia. B.M.J. 1956; 1: 1327.
14.Galil-Ogly G.A., Molochkova V.A., Sergeeva Yu.V. Dermato-oncology. M .: Medicine for everyone; 200S. 872 s.
15. Adaskevich VP, Zykova OS Onychodistrophies in inpatients with psoriasis. In the book: Achievements of fundamental, clinical medicine and pharmacy: Materials of the 65th scientific session of the university staff. Vitebsk: VSMU; 2010: 16S-7.
16. Scheinfeld N. S. Trachyonychia: a case report and review of manifestations, associations, and treatments. Cutis. 2003; 71: 299-302.
17.Reznikova M.M., Trofimova I. B., Korsunskaya I. M. Mycotic infection in patients with psoriasis. Clinic. dermatology and venereology. 2003; 1: 22-4.
18. Rukavishnikova VM Mycoses of the feet. M .: EliksKom; 2003.332 s.
19. Lambert D. G., Dalac C. Nail changes in type Vpityriasis rubra pilaris. J. Am. Acad. Dermatol. 1989; 21: 118-21.
20. Molchanova OV Optimization of therapy for diffuse alopecia and onychodystrophy based on the study of calcium metabolism: Author’s abstract. dis. … Cand. honey. sciences.M .; 2007.17 p.
21. Nanda A., Al-Fouzan A. S., Al-Hasawi F. Alopecia areata in children: a clinical profile. Pediatr. Dermatol. 2002; 19: 482-S.
22. Schlessinger N., Katz M., Ingber A. Nail involvement in pemphigus vulgaris. Brit. J. Dermatol. 2002; 146: 836-9.
23. Adaskevich VP Onychomycosis: clinical forms, modern methods of treatment. Minsk; 2001.22 p.
24. Sergeev Yu. V., Sergeev A. Yu. Onychomycosis. Hybrid nail infections. M .: GEOTAR Medicine; 1998 126 p.

Keywords: discoloration of nails, skin diseases, onychomycosis

Author (s):
Pankratov O. V., Shikalov R. Yu., Pankratov V. G.
Medical facility:
Belarusian Medical Academy of Postgraduate Education, Belarusian State Medical University

How medics work in the “red zone” of an infectious diseases hospital

Medical workers are at the forefront of the war against the virus today. Doctors, paramedics and ambulance drivers.Local therapists, emergency doctors of polyclinics, student volunteers. Heads of clinics, doctors, nurses, laboratory assistants, hospital attendants – it is impossible to list all of them. How do they work in conditions of physical and mental overload, the risk of infection, concern about loved ones? This “RG” was told by the head of the department of one of the re-profiled Moscow clinics. Not wanting to disturb his parents who live in another city, he asked to call him simply Roman Sergeevich.

Doctor, are they bringing patients to your hospital with an already established diagnosis of coronavirus pneumonia, or just with an assumption?

Roman Sergeevich : They bring it as it should be according to the regulations: either with a computed tomogram, which showed the presence of pneumonia, or with a positive smear for COVID-19.

And if the pneumonia was not caused by a coronavirus, is there a risk that such a patient in the hospital could become infected with it?

Roman Sergeevich : According to the international standard, if a patient is hospitalized with community-acquired pneumonia, which is visible on CT, but the test system of the pathogen does not determine, he should be examined for all other infections that could cause pneumonia: pneumococcus, mycoplasma, fungus, etc. But we do not have such opportunities. Therefore, everyone is hospitalized, and no one can claim that this is definitely a coronavirus.As a result, some patients may be covid-negative and are also discharged covid-negative. Either they are covid-negative, and already in the hospital they have positive tests. But it may be that the first analysis was wrong – it can neither be confirmed nor rejected. I think that nosocomial infection also takes place. And for the personnel, in addition to covid infection, this “cocktail” of various infections is also dangerous.

Could such a “cocktail” increase the risk of severe forms of the disease?

Roman Sergeevich : There is an epidemiological regime in our hospital: patients are 2-4 people in the ward and do not leave it.Yes, this ward may have its own viral “set”, but it will not be able to spread far across the hospital. I am sure that the same regime is observed in other hospitals. In addition, UV irradiators are working in the corridors and the windows are slightly open – there is constant ventilation.

How are patients with pneumonia who do not need resuscitation treated?

Roman Sergeevich : We treat as prescribed in the recommendations of the Ministry of Health: upon admission, an antibiotic and new antimalarial drugs are prescribed.In some cases, our doctors “put their heads” – they try to find a therapy with minimal harm. For example, they brought a patient who had just undergone major heart surgery – of course, he is not prescribed antimalarial drugs, which have severe side effects. We use high molecular weight heparins – they show themselves well. There is a certain classification of the degree of lung damage by CT. And if a patient has a CT-3 stage, although he seems to be feeling rather well, then he is immediately prescribed anticoagulants.With coronavirus pneumonia, a systemic inflammatory reaction begins – in fact, it is sepsis. And the use of heparins in this situation has long been well studied and justified. So we got the impression that if a person immediately begins to receive heparin upon admission, he will quickly get out of a difficult situation. True, the recommendations of the Ministry of Health change frequently, and more effective treatment regimens may be found. But what is also very important is not to self-medicate and not to use those drugs that are categorically not recommended by specialists.For example, when the temperature rises, glucocorticosteroids (hormones) and non-steroidal anti-inflammatory drugs such as diclofenac and the like should not be used. It seems that patients who neglected these recommendations go into severe forms faster.

What proportion of hospitalized people, according to your observations, are “getting heavier” and need resuscitation?

Roman Sergeevich : We see only patients who were brought to the hospital – this already means that they have not the easiest course of pneumonia.And any of them can suddenly become “heavier”. Here he lies, and everything seems to be going well, but suddenly he suddenly gets worse. Therefore, the control of saturation, that is, the level of blood oxygen saturation, becomes the base point for determining the patient’s condition. It is guided by a pulse oximeter – a small device that you put on your finger. It shows the number of heartbeats and blood oxygen saturation. If the indicators are normal, everything is fine. If it starts to decrease, we prescribe breathing exercises, we transfer it to a pron-pose, that is, the patient lies on his stomach.This allows the entire volume of the lungs to be recruited and the oxygen concentration rises. If this also does not help, we give oxygen support. Well, and then – transfer to intensive care up to the use of artificial lung ventilation (ALV).

Are there indications of who is most likely to need resuscitation?

Roman Sergeevich : It’s hard to say in advance. But in the intensive care unit, most of the male patients are overweight and with various chronic diseases.

Doctors and nurses interact with many patients. Are they at high risk of infection?

Roman Sergeevich : I am absolutely convinced that with the correct use of personal protective equipment it is impossible to get infected.

But in your clinic, and in many others, there are already people infected with coronavirus among the staff. How did this happen?

Roman Sergeevich : I believe that the main part is employees who did not follow the algorithm of behavior in the “red zone”.For example, they touched the face with their hand or removed the mask. The fact is that in a few hours of wearing her elastic bands, they cut their ears so badly that at some point they are tempted to take it off even for a minute. Another part could become infected in the “clean zone”, communicating with each other. After all, some of the employees have switched to quarantine and are living in the hospital, while the other leaves home after the shift. Violation of the exit mode from the “red zone” is also possible.

Tell us more about this mode, please.

Roman Sergeevich : In the room that I was given for spending the night, I put on overalls over a surgical suit – either rubberized or made of nonwoven material, a respirator and a medical mask, shoe covers, two pairs of latex gloves, and goggles.I leave the clean surgical suit and the new mask in the bag in the clean room of the airlock. Upon our return from the “red zone”, the first thing in the airlock is to spray us with disinfectant solution from a garden spray bottle. Then, according to clear rules, I remove all protection from myself, leave it in the first room (it is then disposed of according to all the rules). I take a shower, go to the clean room, where I put on a fresh surgical suit, a new medical mask – and go out into the “clean zone”.

So you are not reusing your personal protective equipment? Are they enough?

Roman Sergeevich : At first, there were not enough protective equipment, and we tried to find a way to reuse the suits.It turned out that it was impossible to sterilize them. Working in a suit made of non-woven material is, of course, more convenient – it is easier to wear, it breathes. Rubberized, or rather, impregnated with plastic, is more reliable – it is sealed, but it’s hard to work in it for a whole shift. Now there is no particular deficit, except that sometimes there are not enough shoe covers. But we found a way out – with a piece of non-woven material we wrap the leg like a footcloth and fix it with tape. Therefore, scotch tape is now the most scarce material in infectious diseases wards.

Do you get very tired during the shift?

Roman Sergeevich : Probably, we work practically seven days a week.When you take a shower, it seems that you are not so tired. But you have supper – and you are completely cut out. But the hardest, I think, is the nurses. They are on the run all day – giving injections, putting on IVs, distributing boxes with food, then collecting them, renting them out, making beds, helping critically ill patients. It’s a hell of a job.

Did it matter to staff that the co-payments were promised to everyone working with COVID-19?

Roman Sergeevich : I think that in the West, doctors would ask first of all: what will be the salary, what guarantees, insurance, what will happen if I get sick or die? We said: this is voluntary, but it is necessary, although it was possible to refuse.We wrote applications: I agree to work in an infectious diseases hospital. Some part of the staff was immediately weeded out – those who were over 65 years old, who have chronic diseases. Some of them themselves refused, but now I see that they are back, they work wherever they want – some are in the “clean zone”, some are in their usual place. Surcharges matter, especially for middle and junior staff, of course. But, on the other hand, neither the personnel department nor the accounting department still understands how to arrange these days, how to calculate and calculate salaries, etc.

Where are those employees who are still infected?

Roman Sergeevich : In our own hospital. Well, how are they treated … For example, if a doctor falls ill, but in a mild form and feels well, he is hospitalized, but he continues to work. And then the question arises: how to pay for his work? As sick leave or as working days? The schemes are rather stupid – they promise, of course, to pay the entire salary, but it is not clear how. As a result, someone simply hides – has a covid-positive test, but lives in a “clean zone” and works.

But isn’t it risky for both colleagues and other patients?

Roman Sergeevich : Of course, but we are doing a lot ill-considered. Why, for example, it is impossible to gather people who know perfectly well how all this is done – military virologists, hygienists, so that they quickly develop clear algorithms – for different situations? And then people who are far from the topic speak on TV, they say different things all the time: either the virus immediately dies in the external environment, then it lives for weeks. The lady on the radio recommends treating the surfaces for five minutes with an alcohol antiseptic – then the virus will die.But I remember from the basics of medical education that the fatty structures of the virus in alcohol decompose instantly. And then five minutes – it’s just a beast, not a virus. Or recommendations to the staff – to rinse the throat with 70% alcohol after work! This is sheer insanity. Firstly, we have not had such a medicine for a long time. Secondly, maybe some of the male doctors could do this and could, but how do you imagine a woman who rinses her throat with alcohol? Or they water the roads with soapy water – utter nonsense, most likely, the virus does not live on the street.And if he lives, the virologist should say this and give an indication of what exactly the streets should be treated with. If the general leadership of military medicine were transferred, then, in my opinion, there would be more order with much fewer errors.

What is the general mood in your team?

Roman Sergeevich : People are joking, laughing, I have not seen much fear. Although they already say that they are tired, it is time to end this virus.

Toe Fungus Treatment at Home

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Gel “Dolgar” is a natural complex of plant extracts in the composition of the medicinal mushroom cordyceps, enriched with colloidal silver.The composition of the product rapidly penetrates into cracks in the skin, into the nail plates, blocking the multiplication of fungal microorganisms, thereby eliminating itching, unpleasant odor and sweating.

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We treat skin and nail fungus with the help of pharmacy medicines We talk about what mycosis is, what symptoms of skin and nail lesions are characteristic of this disease and how the fungus can be treated.What is mycosis? Mycosis is a highly contagious infectious disease caused by parasitic fungi. It can affect both humans and animals. The infection affects the skin of the face and body, the scalp, mucous membranes (including internal organs), and nail plates. The disease is prone to relapse, so it can be difficult to recover from the fungus without consulting a doctor. Effective remedies for the treatment of toenail fungus at affordable prices with delivery to the nearest pharmacy in our network – online pharmacy Be Zdorov !.If the fungus has already penetrated deep into the tissue of the nails, it will be necessary to first remove the upper layers and only then apply the drug. After cutting the affected areas, it will be necessary to re-do it, according to the information specified in the description. Advantages of varnishes against fungi: Durability – the applied coating lasts up to several days. Ease of use – the products do not stain items of clothing, dry quickly. Nail fungus – causes, symptoms, and treatments for a fungal infection. Maxim Egorov Pediatrician.January 31, 2020. 96890. Nail fungus If treatment is not carried out at this stage, the plate will be deformed, followed by its destruction and damage to healthy toes. Basically, toenail fungus is a consequence of mycosis, in which the feet or interdigital areas are damaged. In the international classification of diseases, onychomycosis is under the code B35.1 and belongs to the category of parasitic and infectious pathologies. Photo: Pathogens of nail fungus. The causes, symptoms and treatment methods of onychomycosis.Nail fungus: the frequency of infection by various pathogens, the stage and severity of the disease. What antifungal drug you can choose How to recognize onychomycosis: symptoms of a fungus. A warm and humid environment is the best place to develop fungal infections. And the climate doesn’t have to be hot; for example, you can create favorable conditions for fungus by wearing shoes that sweat on your feet. The source of the infection is usually another person who is not involved in the treatment of onychomycosis, does not monitor the condition of the nails, or someone who has not taken the treatment measures to full recovery.More than others, the fungus between the toes suffers from people with reduced immunity and metabolic disorders. In general, itching and discomfort with fungal infections of the toes is minor and therefore most people choose to ignore them. But if you do not start the treatment of the fungus between the toes in a timely manner, then after a while it migrates to the nails, which leads to the fact that the nail plate thickens, changes its color and begins to exfoliate. This is especially common in patients with diabetes mellitus and with prolonged use of antibiotics.Getting rid of skin fungus between your fingers is, in principle, easy. How to treat big toe fungus. Prevention is the best way to prevent infection. Tracking the condition of the foot and toes – especially if you have a weakened immune system – for example, due to any diseases, will help to pay attention to any changes in a timely manner. Maintaining good hygiene in public places (not walking barefoot) – such as the gym, pool, or work locker room – is another prevention method.Keeping feet dry. If your feet are prone to sweating, talcum powder or a special powder can come to the rescue, used before putting on socks and shoes. 1. Symptoms of toe fungus. A crack or funnel appears between the toes, the edges of which are covered with whitish or greenish squamous (flaky) skin; The crack may be weeping with exudate; Circular diaper rash with peeling skin appears under and between the toes (intertriginous symptoms). Even if all these symptoms come after many years, you need to start treating the fungus between the fingers right away, because it is a highly contagious and intractable infection.We go to the dermatologist. Before treating, he makes a scraping from his fingers and examines it using microscopy, culture or DNA analysis. Signs of onychomycosis. Most often, the fungus infects the big toes. The following changes in the nail plate indicate a fungal infection. People are in no hurry to treat nail fungus But why, then, such self-treatment of toenail fungus gives good results in a maximum of 10% of cases? Because these remedies themselves are only effective in the early stages of the fungus, when the symptoms are not yet obvious and almost invisible.Manufacturers are often cunning that the drugs are manufactured in Europe and have good active ingredients in their composition. In practice, the most effective against nail fungus (onychomycosis) is Clotrimazole (Climbazole). Recommendations for the treatment of skin fungus on the legs It appears in the form of white pimples on the fingers, palms, feet, later become crusted, redden. They do not itch, do not hurt, but in a neglected state without proper treatment they can dry out and crack, the risk of complications is high. Usually it occurs on a nervous basis or due to the thyroid gland, with diabetes, hormonal disruptions. Treatment of foot skin fungus must be carried out under the supervision of a doctor.If the form is not neglected, and you immediately discovered that it is a fungus, you can use well-known drugs, such as: Ointment, Lamisil-Uno

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