AAD Reading Room | Time to Rethink Nail Care?

The management of nail diseases could be improved by an interdisciplinary approach, particularly between dermatologists and podiatrists.

A change is desperately needed in the way both professions treat nail diseases and disorders, argued the authors of a recent Viewpoint article in JAMA Dermatology.

Those co-authors were Jasmine Rana, MD, clinical assistant professor of dermatology at Stanford School of Medicine in California, and Tracey Vlahovic, DPM, clinical professor at Temple University School of Podiatric Medicine in Philadelphia.

Rana and Vlahovic recently discussed their reasons for writing Point of View with the Reading roomThe exchange has been edited for length and clarity.

You state in the title of the article that there is a need to “rethink the approach to nail disorders.” What about the status quo prompted you both to undertake this study?

Rana: Nails don’t really belong to any one specialty. In caring for patients with nail disorders, we work at the intersection of podiatry and dermatology.

I trained as a dermatologist and Tracey trained as a podiatrist. To provide the best care for our patients, I think we both realized that there are gaps in the specific models for nail disease.

For example, in dermatology, there is a tendency to attribute nail diseases to fungus or inflammatory diseases such as psoriasis instead of recognizing the role of bunions and hammertoes in nail health.

One of the motivations for writing was the increasing rates of antifungal resistance and seeing many patients who come for evaluation of nonfungal nail disease and have completed multiple courses of oral and topical antifungals to no avail.

This is a real call to action to reconsider how we diagnose and treat nail diseases and start thinking about the impact on the cost of our healthcare system and the quality of care for our patients.

The article draws comparisons to the parable of the blind man and the elephant. Can you explain this parable and why it is an appropriate analogy?

Rana: In this story, each individual describes the animal based on the part of the elephant they feel and may be reluctant or unable to accept another perspective. It is not so different for nail disease.

Take the example of onychomycosis. It can be treated with more or less effective antifungals. But when it recurs, what do you do? This is where approaches can differ. For example, a general practitioner may see the role of diabetes and tighten blood sugar control; a podiatrist may see the role of pincer nails and assess underlying bone deformities; a dermatologist may assess other causes of nail dystrophy such as psoriasis and attribute this to the high recurrence rates of antifungal treatment.

It is important to consider all of these factors and more, but in reality, only a small number of these potential contributors can be addressed based on what we know and are comfortable with, which is ultimately a disservice to our patients.

What are your main conclusions?

Rana: The key point to remember is that nail health and disease are not as algorithmic as we would like them to be.

Many different factors (joint diseases, nerve pathologies, immune status, vascular integrity, occupation, infection) can affect the nails. It is important to note that these factors often coexist. We must be able to recognize these factors and treat them when possible.

It is better to have honest conversations with patients than to attempt a futile treatment strategy (eg, repeated courses of antifungals) that incurs costs and other concerns.

Additionally, it is important to recognize that cognitive biases can fail us in the care of patients with nail disease. Even as a physician who sees a disproportionate number of patients with nail disease, I have become aware over the years of how my training influences what I see and don’t see. This has driven me to learn from others, like Tracey, so that I can paint a complete picture for the patient.

What can a dermatology practice do in the short term to fill existing gaps in care?

Rana: I don’t think there is a universal solution, but there are a few things that might help.

Consider scheduling separate visits for patients who have nail issues. If a patient brings up a nail issue during a skin exam, for example, it may be helpful to have them return so you can take the time to focus fully on the nail issue. Nails are difficult to treat, and in a busy office, it’s easy to dismiss them as a last-minute concern. This approach makes it clear to patients that you care and want to address the issue.

Identify local podiatrists and hand surgeons who can help treat patients with nail disorders if your practice does not offer certain diagnostics (biopsy) or procedures (phenol matrixectomy). Patients often get frustrated when they have to see multiple providers, so it can be helpful to vet these providers ahead of time and know their qualifications.

Vlahovic: This article encourages podiatry and dermatology to collaborate and learn from each other in the field of nail diseases. The gaps in our two professions in this area would certainly benefit from cross-dialogue and research. I have learned a lot from participating and working within the Council for Nail Disorders, which is open to the creation of a multispecialty group.

What can the dermatology profession as a whole do in the long term to rethink the approach to nail disorders?

Rana: Nail diseases are clearly important to our patients, but it is unclear whether dermatologists feel well equipped to diagnose and treat nail disorders.

As we mention in our article, there is room to rethink how we provide this care to patients. For example, is it possible to build multidisciplinary “nail clinics” that bring together podiatrists, dermatologists, vascular specialists, and hand surgeons, among others?

Finally, it is unclear why many dermatologists do not perform nail surgery, but this may be an area to explore further. While this may not play a unique role, it is worth noting that reimbursement rates for nail procedures are generally not comparable to other surgical procedures performed by dermatologists. This may discourage trainees and practicing dermatologists from mastering this skill and lead to further delays in diagnosis, particularly of nail melanoma.