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- [00:03]
A
Welcome to season three of Derms on Drugs, a video podcast brought to you by Scholars in Medicine, the best educational platform in dermatology and provider no cost medical providers terms on drugs is we're cutting edge term meets comedy. I'm Dr. Matt Zyrus from Docs of Dermatology and each week I'm joined by my residency buddies, Dr. Laura Fares from the University of North Carolina and Dr. Tim Patton from the University of Pittsburgh. And we use our 70 years of combined derm experience to discuss, debate and dissect the hottest topics in dermatology. It is everything you need to know to be on the cutting edge of durb and you have some fun listening. New episodes drop every Friday on Scholars of Medicine, Apple Podcast, Spotify and other major podcast platforms. And I highly recommend that you download the Scholars in Medicine app to access the full podcast video archive and explore the best derma educational content out there. Real pharma independent coverage of all of dermatology, supported by an amazing AI clinical consultant called Ask Simon. And you know, one of the places that is fantastically useful if you've got new NPS and PAs in your practice. They've got a core dermatology curriculum that is just absolutely fantastic. I think it's also great for residents. But today we have got such a. I can't wait to see if, if I learn any new pearls today. So we've got Dr. Nat, we've got Dr. Nat Jelinek and Dr. Julia Baltz talking about nails. And we are sticking to the stuff that you see in clinic all the time that you effing hate, right? The patients who you're just like, basically just want to be like, there's nothing to do. You just, you're going to look like that. Your nails are never going to get better. And let's see if they've got any, any pearls for us. So first, how did you guys get, you know, how did the two of you get into nails? Like, what was the, what was the insight? Like, you just didn't like, like Mohs was too easy. You wanted some annoying patients like ourselves.
- [01:55]
B
Latin's for punishment now.
- [01:58]
C
I'll let you go first on this.
- [02:02]
D
Yeah. So I did fellowship at UMass, where I did residency. And so about two months before I started fellowship, Mary Maloney was the fellowship director. And she called me to her office, she said, what else do you want to do? And on a whim I said, how about nails? And she's like, done. So she created a schedule where without a lot of thought ahead of time, for my part, I had a medical nail clinic and a surgical nail clinic. I would be partnered up with an experienced med derm and her as the experienced surgical derm. And she said, you gotta write a bunch of papers. You have to give a bunch of lectures. You have to figure this out. She sent me to New York. I spent a couple days with Dick Shear, and I just learned on my own, and I just read a ton and wrote a ton and learned from my own mistakes. So then. Then it became a thing, you know, within a few months, you know, a lot because you're just getting everything that other people don't want to see and then goes from there.
- [03:01]
A
I. I am a. Generally a believer that people who develop a specialty with no. No, like, particular mentor are better than people who develop a specialty with a mentor. Because you get. I think people who have a. Like a. Like a strong mentor often feel like there is an answer, and my mentor knows what it is. And if you don't have a mentor, you're much more comfortable with the. Like, hell, a lot of these people, I just don't know what the hell they've got. And you send them off to somebody else for a consult, they don't know either. And so you're just like, you got to figure out, right, Julie, how did you. How did you get it?
- [03:40]
C
How did you get involved? You know, I, like so many of us, really had not much exposure to nails in my residency, and I ended up doing my fellowship with NAT in Mohs surgery. And I remember when I matched, everyone's like, oh, you must love nails. And I was like, I think they're gross, but it's. So that's what I'm here for. But through the course of my Mohs fellowship, I mean, NAT has a dedicated nail clinic clinic, and it's. So it's not just like people are sent for biopsies. It's like people are sent with refractory onychomycosis, paronychia, onycholysis, all the stuff, right, the stuff that, like, that we hate, and that in turn, you know, seeing that and seeing what an excellent nail surgeon he was, it really, for me, that synergy was really compelling. And as a Mohs surgeon, I then went on to develop a nail specialty clinic, both at UMass and then in our private practice. Um, and it really allowed me to keep that med derm brain turned on. And there are days when it's totally punishing, but there are days when it's super exciting and fulfilling, and, you know, there's nothing Better than getting someone's non dramatified mold better when they've had a crummy finger for five years. Right. So it's, it's cool.
- [04:54]
B
That. Yeah.
- [04:55]
A
That is one of the nerdiest things I think I've ever heard. There was nothing better than getting a non dramatified mold better.
- [05:05]
C
That's my peak right there.
- [05:07]
A
All right, all right, well, let's. Let's get into it. So, Dr. Patton, why don't you kick us off this week? What do you got?
- [05:14]
E
I took the D type paper from July 2025, JAD. The title, evaluation and diagnosis of Longitudinal Melanicia A clinical Review by a Nail Expert group by Ricardo et al. The lead Jelinek was an author on there somewhere. I swear up until like 10 years ago, I was pronouncing it melanikia. Like my residents must have thought I was an idiot and didn't say anything. But that was my biggest challenge in managing melanin. Nikia is getting.
- [05:40]
A
Did anybody have. Did anybody ever have puritic melanicia?
- [05:44]
E
It would have been a nightmare. Seriously. I think that melaninikia is kind of distressing to dermatologists, mostly because if you're not sure about aesthetic lesion, you just biopsy it. But nailed matrix biopsy is not something I think a lot of dermatologists are comfortable doing. So the paper goes in through like non melanin causes of hyperpigmentation, subungal melanoma being the most common fungal or bacterial hyperpigmentation, exogenous hyperpigmentation. Any pearls in diagnosing these entities? It was a tricky paper to read because, like there was the text of the paper and then you had the supplement supplementary materials which had like 50, like great photographs. But then the legend was another supplementary. I just, I think that the editorship like really hurt you guys on this paper. But any pearls for like the, the non melanocytic melania?
- [06:41]
D
Yeah, I mean, I think sometimes you don't know right off the bat if it's non melanocytic or melanocytic. You know, you're. What you don't want to miss is melanoma, which is obviously melanocytic. So you come at these patients with, you know, first off is melanoma. My main responsibility is not to miss a melanoma if it's a non melanocytic. Cause there's sort of three or four groups that they fall into. So one would be the neoplastic group, you know, so you get. Bones disease is the most sort of sinister of the non melanocytic causes of melanicia, any inflammatory disease. But then they start looking like that inflammatory disease, you know, psoriasis, like in planus, et cetera, or then this broad melanocytic activation, which could be anything. And then a few exogenous causes. Where we see it a lot is someone has a pyogenic granuloma, someone uses silver nitrate and they get a stripe of melanicia from that. Clearly an exogenous cause. But now you're in the neoplastic world, they've got a stripe of pigment. Is it melanin? Is it not? Those are instances where for the non melanocytic causes, clipping the nail and. And then having the pathologist look at the nail plate, they can differentiate with Fontana whether it's melanin or not.
- [07:56]
A
So what's. Give me a. I'd love to give me like a one line. Dr. Baltz of like, when does a dermatologist need to like. Because. Right. I know there's the scoring systems and the nail dermoscopy and all that. Nobody's ever going to remember any of that or use it in clinic. Like, what's your.
- [08:15]
C
One nail in an adult is not normal. That's it. One nail melanonychia in an adult is not normal. And yes, you can use the scoring systems and the abcds and melanoma, which we don't really agree with per se, and nail unit melanoma. But at the end of the day, it's just not normal to have one line. And they can be subtle. I mean, we can send you guys all kinds of scary photos that will stop you in your tracks. Right. They're not going to be always this wide band that you know at the door. It's melanoma. So one nail adult abnormal.
- [08:45]
B
But most melania is probably not going to be melanoma. Even one nail, even in an adult. So one of the things that sometimes we'll say is like, well, let's just monitor over time. Do you guys do that? And what is like a safe time period over which to monitor?
- [09:04]
A
Oh, good question.
- [09:06]
D
I mean, I think for. For fingernails and toenails are different. It's different in terms of length of monitoring. Just because toenails are so slow growing for fingernails, for monitoring pigmented lesions, if you're going to do that, it's usually three months for me. You've replaced most of the fingernail in three months. The fingernail grows about 3 millimeters a month. And toenails, it's closer to five or six months to be able to actually evaluate and look for any change. I think Julia is right though. If Our framework is Adult 1 nail melanoma until proven otherwise, then you've got the flexibility to say, okay, this really is benign appearing. It's been there for 20 years. They have all sorts of other reasons, but sometimes you get into the fact where there isn't another good reason. It doesn't look terrible, but it doesn't look. It's not gray and light either. And I think the biggest problem is that when you're in that ambiguous clinical situation, people on the skin would biopsy every time if they're considering melanoma. And they don't do the biopsy in the nail just because they're afraid of doing the biopsy. So the thought process stops if it's ambiguous. Instead of just being as pure as it is in the skin.
- [10:15]
A
How is it so I have never once in my life done a nail biopsy. I think I lied during residency so that I could graduate sending you back. It's.
- [10:29]
B
They wouldn't take you. Don't worry.
- [10:33]
A
Like, do you guys legitimately do the little. Where you cut, you know, you make the two little cuts at the corners and then you flap, you flip it up and then you take the little. Are you basically. Do you stitch it? Like, do you put a little stitch in there? Do you just would like to take a little 32 millimeter punch? I know, I know that I'm asking for something that's probably like an hour long lecture by itself of like, give me the 8 second version. Like, but is this something a normal.
- [11:01]
B
And do you both the nail. I guess that's my other question because.
- [11:05]
E
Yeah, okay,
- [11:09]
C
if we're thinking about nail unibiopsies, right. There are two main techniques. There's going to be a matrix shave, which is Matt, what you were describing, and then a punch biopsy. Right. Nat likes to say, you know, Dick Shear only did punch biopsies his entire career and he's a world class nail expert. Right. He diagnosed melanoma. So a punch biopsy is going to be your entry level nail unit biopsy procedure. And if it's all you have, great, you can diagnose melanoma. Caveat here being if you have a broad lesion similar to on the skin. Right. We don't recommend that our residents just sample what looks like the worst part because you could miss it. You want a broad shave of a broad lesion. So a broadband of melanicia punch probably isn't going to be your best bet. But essentially the way that we would do a punch in the nail is you want to find the origin of that band of melanin nychia. Very important for a punch that you are biopsing in as close to the correct spot as you possibly can. Right. And that's going to be the origin of the melanicia, which is going to be somewhere in the matrix. So that may involve using a nail elevator to push back the proximal nail fold, push back the cuticle, or sometimes you do have to make relaxing incisions. You'd make like two little incisions on either side of where that band is and flip the proximal fold back and then you can see the origin of the melanicchia through the plate. And we put the punch directly through that plate, directly advancing to periosteum. So you should be able to advance to. To bone there.
- [12:34]
D
And no evul.
- [12:36]
C
Yeah, without able.
- [12:36]
D
Right.
- [12:37]
C
We do not able.
- [12:37]
B
We do not ables. Okay.
- [12:39]
C
That's helpful for a punch. We don't avulse. Yep. You just go straight through the plate. And I'd say 50% of the time the plate is going to be stuck in the punch instrument and the matrix will still be in the hole that you've made. So regardless, the matrix will be in there anyway. It's not going to come out with a punch. So what we do is we take a very fine tipped gradle scissor, put that tips down and just sort of pop that little matrix specimen, that little skin out and sort of snip it off. And then.
- [13:07]
B
And how about when you do a shave, are you able seeing the nail then to get more exposure?
- [13:12]
C
Yes. And we actually wrote a really nice paper on nail plate avulsion techniques published last year. But basically you only want to evol the portion of the plate that you absolutely need to. Right. If you, the entire plate, people have more morbidity and recovery. You have nail blade bed contracture and more discomfort. And so we do, we advocate for something called a partial proximal plate evulsion. We like alliteration, but essentially, you know, making your relaxing incisions into the proximal nail fold to reflect the proximal nail fold. And then you're using an English anvil nail splitter to advance transversely across the nail so that you're. You're going to be avulsing just that proximal portion. And so once you've advanced your, your English anvil nail splitter, you then take a hemostat and Grab the. The lateral edge and just curl it over so you've left the distal plate attached so you don't get, like, nail bed contracture as they're healing. You still maintain that structure of the nail bed, but then that allows you to access that area of the matrix where you're seeing that area of pigmentation.
- [14:22]
A
Today's episode has got to be my favorite phrases that I've ever heard. So far we've got the English. I'm imagining asking my staff, get the English anvil nail splitter, please. And then being like, you can have a 15 blade, Dr. Zyrus. That is. All right. There's some, some sort of tourniquet device. Oh, I think I've got one of those in my bedroom.
- [14:46]
B
You may, but we don't want to hear about that. I think a glove, a sterile glove works.
- [14:51]
A
Yeah, the,
- [14:54]
E
the numbing. I did have a question about, because I used to, like we were trained, and you would do, like, this nerve block, and then, and, and then whenever I did that, and even if I let it sit for a decent period of time, whenever I went to do the nail procedure, they still felt it. And so I felt. I found that I was always giving local anesthesia as well. Lido with EPI locally nerve block, it would lido without. And so pretty much I stopped doing the nerve block because it was like everybody needed lido with EPI anyway. And when I just give that, like, all around the finger, I mean, people are like, well, you worry about vasospasm and blah, blah, blah. But like you said, I mean, they bleed all over the place. No matter what you do, do you do both the nerve block and the local? Just the local.
- [15:43]
D
Most of the time we're doing either distal digital blocks or mid phalangeal digital blocks. So instead of going at the base of the digit, you think about the nerves running both sides of the digit. You have a palmar or volar branch and a dorsal branch, and the volar branch is always dominant. And it's the exclusive innervation on digits second, third and fourth digit, but on your thumb and your pinky finger, you actually have dual innerv. So you just can block those nerves anywhere along the path. It doesn't have to be back at the base as we were taught. And you don't have to inject into the, you know, hit the bone. That just makes no sense because eventually you're going to actually hit the nerve or hit the artery there. So it's a subcutaneous injection, which is minimal resistance. And then we Spent a good minute or two just massaging about 1 1/2 ccs on either side of the digits, more on the big toe, you know, less than the little finger. Just massaging it into the nerve while you're chatting with them. It's like a good tactile distraction. And we use something called ropivacaine, which is an amide, which is almost as quick acting as lidocaine and as long acting as bupivacaine, give or take. So the average duration of a digital block anesthesia with Ropivacaine is 20 hours. So we put that in, it acts very quickly. It lasts them the whole first day. And with rare exception, do we need anything else?
- [17:03]
E
And so you don't use the EPI with that then
- [17:09]
C
restricted or constrictive as well? Yeah, so you get a little bit of vasoconstriction.
- [17:13]
E
Okay, cool. Well, I have more stuff from that paper, but like that's 20 minutes into the episode. And I think that the, the biopsy technique and the, the, you know what to do with the longitudinal.
- [17:24]
D
Where.
- [17:25]
E
Because this paper says what Dr. Boltz was referring to, as in an adult, you see it, you think melanoma. And right away I'm thinking, well, geez, oh man, like for a lot of those people, I, it seemed like it would be reasonable to follow those. And I think like, as long as you're sure, you know, get some good images, dramatic scopic images where you measure the length of it and that way you can compare. And three months for the fingernails, five, six months for the toenails. I think that's really helpful. And that's where I'm going to stop my six pack or I'm sorry, deep dive.
- [17:57]
C
One just other addition there to help you in your toolbox is clipping the nail and asking your dermatopathologist to look for melanocyte remnants. Because melanocyte remnants are going to be deposited in the plate when you have a proliferative lesion. So if you're on the fence, you don't know if you want to do a biopsy or patient doesn't want a biopsy, but you think they should get one. It can be something to help you lean you one way or another. And what I tell patients is it's, it's not going to rule out melanoma. But if those melanocyte remnants are there on the clipping, it is more suggestive that this is something concerning and therefore would push us more towards a biopsy.
- [18:35]
B
I think that's super helpful. To know. I always think like, oh, the nail plate, that's not going to take, not going to tell us anything. But it seems like a nice, like, you know, start with this and then, you know, because, gosh, you'd hate to do this big nail procedure and then have it be like, well, that was some, you know, silver nitrate or you know, something else like that. Right. I mean normally you'd have that history but just to be able to say, yes, this is my anesthetic. So I think that's a great take home pearl.
- [19:04]
A
Yeah, I mean that's, that to me gives like a high risk. It's like biopsying a mole on the tip of somebody's nose where you're like, that's what, you know what, that's what somebody needs to invent that, that derma spot thing where you do the tape stripping. That's what we need for nails that be that.
- [19:25]
C
I mean, I think that's sort of the melanocyte remnant.
- [19:30]
A
Yeah, yeah, yeah, I like it. Okay, all right, let's move on. Ferris, what do you got?
- [19:34]
B
Okay, so this is my, the bane of my nail existence is retronicia. So this is in skin appendage disorders Classification of retronicia, A narrative clinical review. Lancaster et al. So you know, this is, I thought this is sort of helpful in understanding what is retro. Retro nia. It didn't have a lot on like how do you treat it? But now I get the experts and you're going to tell me how I make everybody better with retronikia instead of telling them, sorry, there's nothing you could do. Okay, so what is retronicia? So it's retro meaning it's essentially like thinking about, um, you know, the toenail is sort of trying to grow in reverse. So instead of having like a nice normal, well adjusted nail growing forward, it sort of starts growing backwards up into the proximal nail full and it then can keep regenerating. So lots of good little fodder words that we can have in here. So you get xanthonicia. So one of the things that you can see is so a lot of times. So this paper divided it into sort of, you know, three stages, like a acute, ongoing and chronic. So in the acute phase you can actually see paronychia redness around the nail fold. You can start to then get like xanthonicia or yellow changes and then the, the sort of, you know, I think like main feature of retro nychia, which is polymuronicia. I have never. I mean, I think I probably Learned that word. But I sound so smart. Paul. Oh, I believe you have Poly Miro Nikia right now. So it's many part nail. It is also called shrimp nail, armadillo nail or horseshoe crab nail. But basically it's like the, you know, it looks like the multiple little nail stacked on a nail. Stacked on a nail. So that was sort of like the, you know, the pearl to say, what is this? Yes, like yellows. A lot of things that can make your nail yellow, but that like polymeronicia. Think about retronicia. So basically acute stage, or they called it stage A is you don't have that stacking, but you really are starting to see inflammation around the nail bed. My thought is that's probably when like you can intervene with something like clobatas all so it looks angry. Oh, is the ongoing. You can actually start to see like the, like the stack lamella nail starting to peek out and then C is chronic and that's when you know, you don't really see inflammation maybe, but you've seen that the nail bed is like shorted and that's when you get this chronic like stack on stack nail. So that was sort of like, what is it? So you know, like, so how do you, you know, a prevent it? When I see this, I'd say I mostly see it in people who are like athletes. So they're playing sports where they're constantly banging their foot. So I'm like, do not wear shoes that are too small for you. I could, you know, treating the, the inflammation, the, the perinechia with clobatazole. But like, here's my question for you guys. What do you do? Like they come in, they've got this big thick yellow mirror polymironychia. Like do you say, let's avulse the nail, let's see if we can get it to grow back? I have tried that. It always kind of grows back. Still messed up. Do you just say bummer like we're stuck with this? Like, do you say we can take it off and we do a phenol matrix ablation and no nails better than that weird looking nail or like what, how do you, what is your tip for dealing with this?
- [23:10]
C
This is so fun. I mean, I'll start and then Nat, I'll have you chime in, you know, all, all of the above here. So when I think about retronicia, the first thing I'm thinking about is really that acute phase and that's the one that people don't often recognize. That's the patient who is told that they have a infection and they're placed on antibiotics because they have this very painful paronychia of the prostitute fold of a toe. And the subtle signs, I mean the acute phase is defined by xanthanic. Yes. You get sort of more opacity to the proximal plate, yellowing of that plate. You can have little foci of granulation tissue along the nail folds. And then this, you know, painful, sometimes prevalent paronychia. And in those patients, what's happening is right, there's some insult which has led to cessation of nail growth with partial oncomedesis. And so then the matrix thinks, not that the matrix can think, but in my brain it does. The matrix thinks, right, starts to produce a new nail plate. And at this point the nail plate that's still embedded in that, in that space becomes more embedded with this inflammatory cycle. And then you get this ongoing foreign body response and the new nails trying to get in and you have this painful paronychia. So that's the space where recognizing that, that's what the going on. This is a foreign body response to an embedded nail is your, that's your chance for intervention. And the treatment algorithm is very simple. It's exactly like you said, Dr. Ferris. So high potency, topical steroids under occlusion versus IL steroids. You can do IL tack. And then the. For patients where it is sort of refractory to these things, avulsion is the treatment of choice. And I mean we talked about this in our evulsion paper. There aren't a lot of nail conditions. There are no nail conditions besides this where evulsion is going to yield the result you want. So in this case, when you have multiple stack nails beneath the proximal nail fold, evotion will cure the issue.
- [25:27]
B
So is there a way that you prevent it from coming? So I have seen this happen to my own daughter. Like she, she didn't tell me until it was like, oh my God, this is like a mutant nail. Like, I can't believe you didn't tell me about this. And then I was like, your shoes are like two sizes too small. So that was probably part of it. But then I was like, okay, we'll get your nail. But like a Vulcan, I've seen other people with this happens like they, they evolve the nail plate. How do you get it to grow back? Normally I see it grow back still with retronic yet like is there. Should you be treating with clobatas all as it's regrowing? Should you be trying to do karma, like urea cream, like, what can you do to prevent it from growing back in this weird way?
- [26:12]
D
I mean, I think it's about predisposing factors. You know, anytime you get onychomedesis, you can get retronicia. So it's proximal ingrowing. The nail hasn't, for a variety of reasons, isn't escaping from under. The proximal nail fold grows in, and you get this ingrown nail proximally. So what's causing the onychomedesis? As you said, it could be shoe fit. Congenital malalignment that is not picked up until adulthood is very common for this. And at that point, Right. You have a biomechanical problem, and there isn't an easy fix. We can talk about the surgical fixes of that, but none of it's easy. And so for these people who get recurrent retronychia, you got to figure out what's causing their onychomadesis. Most of the time, it's shoe fit and trauma if it's on the biggest, you know, the big toe. And so it's orthotics to maximize toe fit and shoes, like, really getting your shoe fit. But if it's someone who's a hiker, basketball player, tennis player, you know, really active, and that's the way their feet fit in shoes, they're going to be set up for this.
- [27:14]
B
They are pickleball players. Now, a new pickleball injury we need
- [27:18]
C
to think about and call it pickleball. Now, pickleball.
- [27:22]
B
Do we really. We're going to coin that here? Pickleball. Now we're gonna start.
- [27:26]
E
It's a little bit nicer than what, like crab nail or horseshoe crab nail.
- [27:31]
B
I know.
- [27:31]
E
Yeah, that's. I think pickleball is a little bit nicer.
- [27:35]
B
Yeah. And then I like the term onychomedesis. It was like a reminder of. It's basically on. It's like proximal onycholysis. Like, it's. And this is really one of the, I think, few conditions where you truly see the nail lifting at proximally, not distally. So.
- [27:51]
D
And this is one of those.
- [27:53]
A
So my takeaway from that, my takeaway from the whole discussion is if you've got onychomedesis that is chronic, just go get your nail taken off and get a phenol matrixomy. Because unless we can send them to Dr. Jelinek or Dr. Baltz and they can do a complex surgical repair like, it just. It. It seems hopeless. Seems hopeless. To me.
- [28:21]
C
Well, maybe not hopeless.
- [28:23]
B
Yeah.
- [28:24]
C
I mean, if they have what we would call like end stage or terminal malignment, the, the things that you see, Right. So if you have, you know, someone who's had malignment that's been just like compounded by the, these external factors for 50 years, you end up getting something called the disappearing nail bed sign where the. Because this nail has been onycholytic for so long, the pulp herniates proximally and that gives you contraction of the nail bed. And then the nail plate can never reattach to the nail bed so that you get this smaller and smaller triangular nail. And then you get, you know, then it just starts to stack and stack and stack. And so you have this like little mini shrimp nail.
- [29:11]
D
The only other thing I'd say is that for these end stage malalignment, there's a paper came out in 2025 by reshare and there are surgical realignment procedures that help even the more severe patients. It's just a really big surgery to go through and it's not clear that it cures people. But for mid, not super severe cases, there are surgical options for people who otherwise would be, you know, basically getting finalized and having no nail.
- [29:41]
A
So why hasn't anybody come up with a basically a toupee for nails? We're like, hey, we're just going to get rid of your nail. But here's a little fake nail that
- [29:53]
B
you can press on nails. They've been around since the 80s. You just buy the nail, you put it on.
- [30:00]
A
You need a knee, a new to, to put it on the
- [30:05]
B
special occasions. You just press on the nail.
- [30:09]
E
Will it stick to the skin?
- [30:12]
D
I think it would not. Great.
- [30:16]
A
I think there's a huge product. I think there's a huge market out there for this.
- [30:20]
E
I'm picturing people walking around with little hair on their nails because you called it a toupee. Like I don't think anyone wants that look.
- [30:28]
C
Very tone out.
- [30:30]
D
I think it's a good look actually, Tim.
- [30:32]
E
That's right.
- [30:34]
A
So we cannot repair your nail, but we can do a hair transplant.
- [30:38]
C
Hair is big right now. Hair is big.
- [30:44]
A
That'd be the worst hair transplant.
- [30:49]
B
Actually. I'm gonna ask off the wall, off topic question. But since we said hair is big right now and oral minoxidil is big right now. Oral minoxidil helpful for nail growth. Brittle nails, slow growing nails. What people don't like about their nails. Yay or nay?
- [31:07]
D
Yay.
- [31:09]
A
I mean the literature says yes, this Is part of my, like, weird supplements talk. I believe in keratin supplements, the combination of biotin and pyridoxine. Either one by itself does nothing. And then oral or topical minoxidil. So there's Data for putting 5% minoxidil on your cuticles every night, and it speeds your nail growth up by 20%. Now, Dr. Baltz and Jelinek, am I making all of that shit up? Because I've never, like, I can't tell if it works. I just. It's. It's in the literature.
- [31:46]
C
No, it is in the literature. And I think the only caveat I have with the topical minoxidil for patients is just if they have pets that is toxic to animals. Me personally with four pets, I, you know, don't do that. So that's the main thing. But, yeah, that is out there. That can be helpful.
- [32:05]
E
I would say. Pincer nail deformity is not an infrequent complaint. Is there any fix to that? Like, that was another one where when I see that, I'm just kind of like, there's nothing we can do.
- [32:16]
C
Yeah. Pins or nails are also really tough. So depending on if we're. If we're talking finger or toe. Right. So if we're thinking multiple, first off, you see multiple nails, you want to do a. Just a quick drug search. Because beta blockers can lead to pins or nails, and you take them off the beta blocker, the pincer nails can normalize. And I actually had another patient, she developed pins or nails of all 20 nails on a medicine for metastatic thyroid cancer, which she has to stay on. So her nails are saying that way, but. So that's something. Just looking at their, their med history. If it's multiple nails, if it's multiple toenails plus lateral malignant of the great toenails, that is in line with something called familial pincer nails. So it's genetic autosomal dominate with incomplete penetrance. And so if you see. There we go. Lateral malalignment plus. We're talking pincer nails here. If you see lateral malalignment plus pincer nails on the lesser toes and sometimes medial malignment of the lesser toes, then you're like, hey, what did your parents nails look like?
- [33:28]
D
This is.
- [33:31]
A
That's a. By the way, that's a common, common phrase in my clinic.
- [33:34]
B
Hey,
- [33:37]
A
we're from Rhode island now.
- [33:38]
D
This is at the Rhode island thing, you know?
- [33:41]
A
Yeah. What you think was gonna happen, Ned,
- [33:45]
C
do you want to take on what you do for one pincer nail on a finger. What's your workup?
- [33:51]
D
Yeah, I mean, I think I start with etiology. Right. Always get an X ray of these people. One, they could have a primary subungual tumor causing it. Two, if they have a pincer nail from arthritis, in that case, which is the most common etiology, they can get a secondary hyperostosis like a dorsal traction osteophyte. That helps you because the bone won't go away. So then treating the bone as well as widening the nail bed becomes part of the procedure. So X ray is very helpful with one nail, pincer nail. I mean, I try to limit my surgeries to those people who are symptomatic, you know, and it's easier on bigger nails, little nails. You can, you know, if you're going to narrow the nail, you can leave them with a very thin, useless nail. So they should have somewhat wider nail. And it's a pretty high morbidity procedure unless you're just phenylizing the matrix horns to widen the nail bed. So you want the punishment to fit the crime. But there are good nail bed widening procedures which work reliably. But now you're just getting into more advanced surgery where you, you may, you're going to be operating above the bone. Antibiotics, more pain, need for immobilization afterwards versus phenylization, which is straightforward.
- [35:02]
A
Is there like, are podiatrists like super, like, can you just send these people to any old podiatrist and be like, go see podiatrists, they'll do whatever. Or they hate, hate toenail surgery as much as we hate toenail surgery.
- [35:17]
D
I think nails are the redheaded stepchild, not just for dermatology, but for podiatry and, and hands too, by the way.
- [35:24]
A
Patton's kids are already headed stepchild.
- [35:27]
C
I'm in her room right now.
- [35:28]
D
Yeah. So, yeah, no, I don't think it's as simple as sending it to podiatry for that. I think there are podiatrists that are experts in this and really know their way around it, but many of them don't. And you know, this sort of idea that everything is onychomycosis and everything is treated with nail avulsion. There's a lot to that when you see your patients go to different, different referral sources. So I'm cautious about that. Podiatrists are great and they do certain things that no one else can do. No one else is fitting orthotics. No one else is really doing nail debridement for People who can't do it on a regular basis. And they do most of the bunion surgery, which is awesome. But for these more nuanced nail problems, it's like, find someone who knows nails who specializes in it.
- [36:21]
B
All right.
- [36:21]
D
Okay.
- [36:22]
A
All right, we're going to jump onto our last nail topic here, and I will keep this quick. So I did two articles on finger and toenail onycholysis. So first, it was fascinating to me that the finger and toenailysis was written by two authors whose last names are Zayas and Ziak. Z A I A S and Z A I A, K. That seems like it would be unlikely to be coincidence, but I believe that it is. And then the other one was from you. Let's see here. Dr. Jelinek, I think you were an article on it or an author on it.
- [37:03]
D
Yeah.
- [37:03]
A
And the best part. So, right. Onycholysis, like, sucks. Patients come in, they hate it. I've got, like, a couple of specific questions because.
- [37:12]
B
Right.
- [37:12]
A
To come in. What you think about with onycholysis. Okay. You're on any photosensitizing drugs. I used to get them sent to me for, like, was there contact dermatitis causing your onycholysis? And nine times out of ten, there was nothing. Like, they just had on, like, onycholysis. It was probably trauma from, like, tap, basically tapping things. And you just. Basically, all I ever could do was tell them, keep your nails cut short. Maybe it'll grow back, maybe it won't. Like, is there anything like some like, oh, my gosh, you should have been telling him to do this. Like, put. I was always like, maybe I should tell them to put superglue under there. Or like, you know, is it. Is there a chance it's going to regrow? Like, that was always my thing is, like, is there a chance it's going to reattach or is it like, you're just going to have this from now on? Like, once you've got chronic onycholysis, you're done, your nail and your plate are separate. Forget it.
- [38:06]
D
Did you know? Definitely not that way.
- [38:10]
A
Or now, wait.
- [38:12]
E
So, Patton, would you actually ever tell someone to super glue.
- [38:16]
A
No.
- [38:17]
E
I always thought about that. My. When you said that, I'm like, oh, my gosh. He thought about that, too. Like, it. To me, it just makes sense. Like, this will get it to stick. Yeah, I never did.
- [38:28]
A
Never did it either.
- [38:29]
E
Good. Good for us.
- [38:31]
A
Based. Based on the looks we're getting from Dr. Jelinek and Baltz, it was probably good that we we held that one in, but. All right, so once you've got a chronic onycholysis, is there any chance it's going to stick again?
- [38:43]
D
Yes. So if we're talking about fingernail onycholysis in the absence of psoriasis or lichen planus or onychomycosis. Right. So what Ralph Daniel terms simple onycholysis, it's not an easy fix because so much of it is patient education and behavioral modification of the patients who don't want to modify their behavior. So these are 15, 20 minutes of counseling in great detail and having people undo what they like to do. So most of the time it's an irritant problem where something about what they're exposing them to, irritant wise, it could just be soap. And water is toxic to the anatomic cement substance that holds the nail plate down to the nail plate. So they have to basically practice total irritant avoidance and irritants. Again, soap, water, any cosmetic product, really, anything at all, they should be dry, should be cut short to avoid the lever that can continue to lift the nail, the lever phenomenon.
- [39:52]
A
And how the hell are people supposed to do. Because I'm picturing. So as you're saying that, I'm like, okay, so you wear a little like condom over here, but then that's going to keep it moist under there. And now you're going to get yeast.
- [40:03]
D
If you're catch 22, it's cotton gloves under waterproof, like nitrile gloves for all wet work except for showering, after which they use a blow dryer and cool to dry things off. So for all cooking and cleaning, it's cotton gloves under vinyl gloves. It really helps to have a handout that legitimizes this because this is not what people want to do. It's hard to cook in gloves like that. But Dick Shear, I remember him teaching me this very early on. He said that this will work in about 90% of patients and, and the other 10% have psoriasis. And if you biopsy that 10%, you'll see psoriasis. You just have to undo people's tendencies towards washing their hands, putting things on their nails, sticking orange sticks under their nail, rubbing tea tree oil around their nail. And the hardest patients are the ones that can't do it easily. Bartenders, hair salon technicians, scrub nurses, cleaning folks. You know, those people who have their hands, swim instructors have their hands in water all the time. It can be as simple as soap and water to those susceptible. But once you identify irritants as the main cause and you teach them irritant avoidance, they get better. So quick, plug our last book, the sheer and Daniel 4th edition does have a handout on this condition that you can just like print out and give to your patients.
- [41:30]
A
And if it's coming from a book that really legitimizes it.
- [41:32]
D
Yeah, yeah, okay. Yes.
- [41:36]
A
You know, I loved you guys article on. On simple article, Mike. On simple onico lysis. Which by the way, Pat in Ferris. Wasn't Velez a medical student of you guys?
- [41:47]
B
Nicole Velez?
- [41:49]
E
Yeah. She practices.
- [41:52]
A
Yes. Did she come and do residency with you, Nate, or.
- [41:56]
D
It was either.
- [41:57]
E
It was either us or Harvard and for some reason went to Harvard.
- [42:01]
B
Hard to imagine.
- [42:03]
D
Superstar. And she is awesome. And she was a great fellow. Yeah. So she's back in Pittsburgh, but she did a year with us doing fellowship.
- [42:11]
A
Okay. But so yeah, you guys did a great. The favorite part of that article because it was like kind of a response to somebody else's article in which. In which you're like, no, they said that all of these cases of simple onychomycosis or simple onyolysis healed with casabitriene and betamethasone, which it'd just be very unusual in our experience. And when we looked at the pictures, they just looked so much like psoriasis type nails that we see all the time. They were just very interesting cases of simple onycholysis. It would just be. You guys did a very nice job beating around the bush without. Without calling us beta.
- [42:49]
B
So can I ask you if it's not. If it's simple onycholysis, it's not psoriasis. Is there any role for steroids? Like, I mean, presumably some of the irritant is inflammatory. Maybe like do. Or is it just like. No, just quit doing what you're doing. Wear the cotton gloves with the night trial, change your life, be the weirdest rib instructor and move on.
- [43:11]
D
As opposed to chronic paronychia where there is a role for corticosteroids there I don't think there is for simple onycholysis because it's just an. An irritant phenomenon and there isn't this cycle of soft tissue inflammation.
- [43:25]
B
Okay.
- [43:27]
A
I think maybe 40 of prednisone for six months might.
- [43:30]
B
All right, I'm going to look for that. That handout. That would be really helpful.
- [43:34]
E
That sounds very difficult to talk someone through.
- [43:38]
B
Yeah, yeah.
- [43:38]
E
And I would just say, I don't know anything about nails. I'm an idiot. Patients would not find that too far fetched. I'll Be like. But there's a nail expert who wrote a whole book. Take this paper and do it.
- [43:49]
B
Yeah.
- [43:50]
C
And one other thing. When you're thinking about onycholysis, if you do have one nail onycholysis, you want to make sure that that's not hiding a malignancy. Right. So whenever you clip it back, send your clipping because it could, you know, one nail. Onicular dystrophy. You want to think about a nondramatic fight mold infection, especially if there's an associated paronychia. So sending that clipping for PAS gms and we do PCR red than culture and then inspecting the nail bed because you want to make sure they're not hiding a tumor under there.
- [44:28]
B
Wow. Good advice.
- [44:30]
E
Okay.
- [44:31]
A
Okay. All right. That's. That is a pretty good hit on nails, I think where they. We. You know, we did our best to make nails sexy again. We had to get that in. Now, Patton, I can't wait to hear what your trivia for this week is going to be.
- [44:46]
E
It's nails in pop culture.
- [44:49]
A
Okay. Nails. And you guys do. Patton already told you the rules, so we'll just get right in.
- [44:54]
E
Yeah. So let me finish and then everyone can answer. All right, ready? In the 1975 blockbuster Jaws, while the attendees of the town hall are arguing about shark attacks, what does Robert Shaw's character Quint do to get everyone's attention?
- [45:13]
B
Scrapes his nails on a chalkboard.
- [45:15]
A
Nails on a chalkboard.
- [45:16]
E
Yep. Scrapes his nail down the chalkboard. It's a great scene. Great scene. Cyrus was first. Ferris gets half a pack because with
- [45:25]
B
video delays, very intricate scoring system here.
- [45:30]
E
Yeah, yeah, it's official. It gets reviewed like Trump will call in to favor certain people if they get eliminated. You're. You're in good hands.
- [45:41]
A
Just for any of our listeners today. The soccer game is later today, and it was just yesterday that that the red card on the American guy got rescinded. Just in case you didn't know.
- [45:51]
B
We're apparently because our president called to request it.
- [45:54]
E
But maybe play a role.
- [45:57]
D
Maybe.
- [45:58]
E
All right, number two, Johnny Cash's song Hurt, released in 2002, is actually a remake. What band was the original artist releasing their version in 1994?
- [46:14]
A
Nine Inch Nails.
- [46:15]
D
Yeah.
- [46:15]
E
Ferris, I think said it first.
- [46:16]
B
Julia may have beat me.
- [46:18]
C
No, I didn't say it at all. No, that was you, Ferris. None of it.
- [46:23]
E
All right, last one. Our guest.
- [46:25]
A
Wait, the. The answer was Nine Inch Nails.
- [46:27]
E
It was Nine Inch Nails.
- [46:28]
A
You know, he went to my high school.
- [46:29]
E
Trent Reznor. One award Away from an egot. If he gets a Tony, he has won an Emmy and a Grammy and an Oscar.
- [46:38]
B
Wow.
- [46:39]
A
Wow.
- [46:40]
D
What have you won?
- [46:42]
B
That is the best trivia of all. I didn't even know an egot was a thing, so.
- [46:46]
E
Oh, serious.
- [46:48]
A
So he needs an Emmy, a Grammy, an Oscar and Tony. So he's got everything but the Oscar.
- [46:54]
E
No, he has a. He has two Oscars. He does. He actually right now is a very renowned movie score guy. That's kind of what he does now. He doesn't even do, like Nine Inch Nail stuff.
- [47:06]
D
Wow.
- [47:07]
E
Actually, that's not true. I think they released an album, 25. But he's more. Much more successful on the Oscar side now.
- [47:15]
A
Okay, okay.
- [47:16]
C
All right, all right.
- [47:18]
E
So we did movie, we did music, and now we have history. In 1517, Martin Luther is reported to have sparked the Protestant Reformation by taking what action?
- [47:28]
B
Nailing the thing to the door.
- [47:32]
E
Nailing the thing to the door. I will. I'm. I'll take it. And Dr. B.S. gave this as an answer.
- [47:38]
C
I showed how one nails. Yeah.
- [47:41]
E
So that's a tie there. Half a point for each of you. What.
- [47:44]
B
What did he nail? It was some very important proclamation.
- [47:48]
A
I think there were 90. I think there were 95 points of, like, what the Catholic Church was doing wrong.
- [47:56]
E
95. Theses controversy, you know, did he actually nail it? Whatever. But that's what all the historians say, so.
- [48:04]
C
Yeah.
- [48:04]
E
All right, good trivia. I don't. It was so confusing.
- [48:06]
A
I don't even know.
- [48:07]
E
I think Ferris won.
- [48:08]
B
She came away with two points for this one, but not very well earned. But this was great, you guys. Thank you. This was so.
- [48:15]
E
Thank you so much.
- [48:17]
A
And I want to thank all of our listeners for joining us. We hope you laughed once or twice. We hope you learned a few things, but mostly we hope you're planning to join us again next week. Until then, I'm Matt Cyrus.
- [48:27]
E
I'm Tim Patton.
- [48:28]
B
And I'm Laura Farris. And we are Derms on drug.