Conservative management onychogryphosis

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Can anyone help me with some tips for treating a severly gryphotic nail without cutting it! I am a student and a patient I had with learning difficulties refused to have his nail touched. I realise there are issues around mental capacity etc but wanted to explore every avenue before surgery under a GA becomes likely.

He also refused to have it filed but I don't think that would have had much impact other than to try and gain his trust. I would also like to know what would happen eventually should the nail be left? Will it just keep on growing (like pictures from Guinness Book of Records) or do they tend to detatch?

Advice will be gratefully received.

 

Although I've never personally tried this, you could ask the patient to dress the nail with an occlusive dressing of 20-40% Urea cream. This should denature the nail to a soft consistency, and may make it possible for autolysis to take place.
I would first try to obtain shavings from the nail and send to the Mycology Lab for analysis first. In the eventuality that the gryphosis does lyse, then you could always advise some antimycotic treatment and hopefully improve the new nail's condition.
Might be worth trying if patient isn't too hurried for a result!

 

I concur but you can get a prescription for the the "nail pen" which is 50% urea. It will work.

 

Thank you, I have not heard of a 'nail pen'. I think encouraging autolysis would definitely be beneficial for this gentleman, particularly as the slow nature of the treatment would be less alarming for him and hopefully not put him off any future podiatry treatment!

 

Keralac is the name brand and I can't remember if they were the ones with the pen or not but it will work either way. Good luck and study hard!

 

Hey hmb1v07,

Not sure how your sharp debridement skills are, but if you give teh nail a good soak with hydrogen peroxide, the keratolyitc nature of teh peroxide will soften the nail substancially and you can debride it with a scapel. You may to need to apply, debride, apply, debride etc. etc. Alternatively (and this is always a contentious issue but I'm a fan) you get the drill, grab a diamond burr, and grind it away, the burr (provided it's not vibrating from being bent) will be so gentle in reducting the nail.

Good luck!

 

In addition, you should also consider giving the patient valium or another sedative and try debridements that way. No GA would be needed but if the patient can't calm down then IV sedation and a permanent procedure might be an option. Of course if this is onychomycosis then consider oral treatment. In answer to your question, yes, this will look like something out of the world book of records if not treated and then there is the risk of it getting caught and tearing in which case you will have to do something interventional.
Again, good luck

 

I think some form of sedation would be beneficial and possibly necessary even if just to apply the previously suggested urea remedies, as unfortunately he becomes agitated very quickly.

Thank you for the advice.

 

May I suggest a tungsten tip burr instead as this does not get hot and tends to cut rather than polish the nail. Patients generally respond better using this type of burr than a diamond tip.

 

Do you find them quite aggressive though? I find taht they tend to remove too much material? But then again, in this case.....

 

I find them perfect for sensitive nails. By lower the speed you can slow how much comes off. Excellent for those patients that tend to have a strong reflex when using a diamond tip.

 

I've been practising for a year and have a new nursing home to attend. Most of the patients have not had podiatry treatments for over a year but some of the patient's have gross onychogryphosis and I didn't seem to make any impression on one lady's hallux nail which grew mishapenly 3cms from the nail bed. The nippers (large canitlever) could not get a purchase and smaller nippers didn't help either. The nail didn't crumble but was rock solid.

I'm going to speak to some of my colleagues but I also wondered whether the Home's policy of varnishing the patient's nails had made them doubly impenetrable!

I haven't heard of a nail pen previously mentioned so I will look into that too.

Many thanks to all the contributors!

 

Hi valerie,
Quite frankly I am appalled at what you say.
Nursing homes have a duty of care to their residents and to not provide any form of Chiropody/Podiatry for over a year is totally unacceptable. These are vulnerable elderly person with compromised immune systems who deserve better than that.
I would say that this home has failed in their Duty of Care and I would certainly be raising this matter with the appropriate regulators.

Regarding the treatment of these nails, I would forget about trying to cut them, for, as you say, it's almost impossible to get any purchase. A nail drill with a coarse burr will remove a certain amount of the bulky nail, but it may take serveral sessions and the patient should be made aware of that. I also agree that using H2o2 will help soften the nail, but it won't work until you have removed the nail varnish !

Hope that helps.

regards

Catfoot

 

Onychogryphosis
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Onychogryphosis Is Associated with Dermatologic and Vascular Disease: A Case-Control Study of the All of Us Research Program
Zi-Ning Choo, Shari R Lipner
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