Fungal nail and nail surgery

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I have a 25 year old female patient who has a longstanding Right 1st fungal nail. She has tried the usual topical treatments and is not keen to try oral antifungals. She basically wants rid of the nail and has asked to have a TNA with matrix phenolisation. I am experienced in nail surgery but I have to say I have never removed a fungal nail of this type. The nail plate is not intact but friable and I am concerned that as the nail plate will not be able to be elevated in the normal way, it may be better to dissect off or drill the nail away.
Any thoughts or experience of this kind of nail and TNA??

 

If it is not possible to grasp and cleanly avulse the nail base then it is likely that phenolisation will be ineffective. The only solution in such a case would be an incisional technique of the Zadik's variety.

All the best

Bill Liggins

 

Hi footcredible,

I assume there is matrix involvement and that the entire nail plate is dystrophied? I have avulsed a number of these with and without phenol. In a younger person, where there is no clinical evidence of a traumatised matrix, sometimes the nail plate will re-grow without tinea, so I will not use phenol and advise topical application of a fungicide to the nail bed once the wound has healed.

Removal is slightly different from that of an un-infected nail, as Bill rightly highlighted; clean avulsion of all the nail apparatus can be tricky as it will crumble and split. Any concerns, I would refer on to a Pod surgeon for surgical removal of the matrix if that is what she has decided upon.

Cheers,
Bel

 

Thanks for the useful advice. Yes, the whole nail including matrix is affected and there is possible trauma to the matrix as the patient recalls the problem starting when she did a whole snowboard season in tight boots and the nail came off. Will reassess and possibly refer on.