Year : 2014 | Volume
: 7 | Issue : 4 | Page : 201--202
Role of chemical peeling in nail disorders
Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, Delhi, India
Dr. Chander Grover
420-B, Pocket 2, MayurVihar, Phase-1, Delhi - 110 091
|How to cite this article:|
Grover C. Role of chemical peeling in nail disorders.J Cutan Aesthet Surg 2014;7:201-202
|How to cite this URL:|
Grover C. Role of chemical peeling in nail disorders. J Cutan Aesthet Surg [serial online] 2014 [cited 2020 Mar 29 ];7:201-202
Available from: http://www.jcasonline.com/text.asp?2014/7/4/201/150738
Not every nail surface abnormality is a disease, so every surface change does not require medical treatment. Many of these are better handled by aesthetic procedures.  There has been an increasing role of lasers,  acrylic nails, and gel nails  being used for the management of nail disorders. This issue carries an important study, titled, 'Nail rejuvenation by glycolic acid'.  The study is important because it is presumably the first of its kind, exploring the role of chemical peeling in nails. The authors provide an interesting perspective on the use of glycolic acid for 'rejuvenating nails'.
Chemical peels aim to increase the shedding of keratinocytes that are replaced by an increased proliferation in the lower layers of the skin. However, this may not be easily extrapolatable to nails, because the contribution of the nail bed epithelium to formation of the nail plate is minimal.  The nail plate is a specialised keratin structure produced almost entirely by the nail matrix, through a special type of keratinisation (onychokeratinisation).  In fact, the superficial part of the nail plate surface is produced by the proximal/dorsal matrix,  which is totally shielded while doing any chemical peeling. Nevertheless, peels can have an important contributory role in improving superficial nail abnormalities; although, the effect on the deeper irregularities remains to be seen. Furthermore, how much effect it can have on the pigmentary changes is an open question, as the origin of pigment in the nails is generally deeper down (again, mostly in the matrix).
The investigators have chosen 70% glycolic acid and used it for 'dry, rough, discoloured nails, and hyperkeratotic nail conditions'. Though an improvement in rough nails can be expected, how much effect the peels would have on discoloured nails will depend on the cause and depth of discolouration. With regard to the 'dryness' of the nails (this happens to be a confusing term), the one can expect that onychoschizia and onychorrhexis (of various causes) may benefit, although the 'dryness' in itself may worsen.
The key feature of a cosmetically pleasant nail is the translucency of the nail plate, for which the peels are not likely to be of any help. The peels can improve the surface of the nails plate (as seen in this study) giving it an overall smoother appearance, which can be further enhanced using nail art techniques.
The essential precautions that I would like to reinforce in the minds of the readers planning to initiate nail peels are, ensuring adequate moisturisation and protection of the cuticle. The treated patients must be motivated to apply liberal amounts of emollients, both before and after the procedure, to counteract the cumulative drying effect of acetone, peel and repeated cleaning, which themselves can precipitate increased brittleness of the nail plate. Guaranteeing the integrity of the cuticle and its protection during the procedure is another crucial point. Similar to many other cosmetic procedures, this can be a time-consuming, slow procedure, hence, a realistic expectation alignment for the patient needs to be done before committing any guarantee of results.
This study, being a preliminary study, is constrained by a small number of patients. To derive more concrete conclusions, well-controlled studies with a larger number of patients will be needed. The future may witness evaluation of other peels of medium to deeper depth, combination peels, or sequential peels. Similar to any other novel therapies, the success will depend more on careful patient selection, as only a subset of disfigured nails can potentially benefit. Better still, nail peels may be used as an adjunct therapy to other treatment options. Although no patients with trachyonychia are included in the present study, in the author's opinion, they may be ideal candidates for such a procedure. Trachyonychia is mostly a self-improving condition, not warranting toxic systemic medications.  Peels can offer a viable option to treat nailplate irregularities. This study includes patients with onychomycosis, although I would suggest caution in this or any other infective nail condition. The peels can probably enhance the efficacy of topical treatments for onychomycosis, but the potential to worsen the infection by distorting the nail architecture needs to be considered. Similarly, in cases with nail psoriasis, a distinct theoretical possibility of inciting Koebner's phenomenon remains. Furthermore, nail pits of psoriasis tend to be deeper as well as of uneven depth. The degree of improvement the peels can produce remains to be proven. One will also need to be careful when dealing with thin nails (age-related or with lichen planus), for obvious reasons.
Chemical peels do not offer aetiological treatment. Hence, the need for repeated as well as maintenance sessions need to be explained to the patient, depending on the etiology. Increasing the number of coats may be helpful. In future, better formulations for use on nails (e.g., lacquers) that could be left on for longer periods may be helpful. The optimal duration is indeed difficult to standardise. As of now, peels seem to be a good option for those looking for quick rejuvenation when the nail is otherwise healthy. The future holds promise, if more objective measures of improvement, such as, scoring system for surface abnormalities, evaluation by independent observers and optimum treatment schedules can be devised.
I would like to acknowledge some valuable inputs received from Dr Soni Nanda, Consultant Dermatologist, Shine and Smile Clinic and Max Hospital, Delhi.
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