Journal of Cosmetic Dermatology
Volume 1 Issue 1 Page 24Issue 1 - 29 - January 2002
To cite this article: Robert Baran (2002)
Nail beauty therapy: an attractive enhancement or a potential hazard?
Journal of Cosmetic Dermatology 1 (1), 24–29.
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Nail beauty therapy: an attractive
enhancement or a potential hazard?
• Robert Baran
• Cannes, France
Correspondence: Robert Baran, Nail Disease Centre, 42 rue des Serbes, 06400 Cannes,
France. E-mail: firstname.lastname@example.org
*The length of artificial versus natural nails is not mentioned in the article.
Keywords : artificial nails, systemic danger, bacterial and fungal infection
Nail coatings which harden upon evaporation and coatings that polymerize may produce
some reactions at the site of application to the nail itself, and distant reactions when small
amounts of nail cosmetics are transferred by the hand to other areas of the skin.
Nail cosmetic hazards may be occupational, or accidental, especially in children.
Individuals wearing artificial nails tend to wear their nails longer, and are more
careful about their nails when washing their hands. The sanitary conditions for
the application of artificial nails are therefore paramount in preventing nail
Our present concept of nail beauty depends on the shape of the nail, its texture and its
. The latter will be briefly described with special reference to the various
hazards related to nail cosmetic procedures.
Many people perceive that in nails of equal length and corresponding contour, a painted
nail is more attractive. Renewed interest has been awakened in sculptured artificial nails.
Diamonds or emeralds have been fixed into elongated nails, and intricate jewellery
attached to the free edge. The art of the jeweller has been engaged in the manufacture
of artificial nails, and pre-formed nails in gold or gold plate may be decorated with
precious stone insets.
A more conservative decoration is called 'nail art'. Painted designs are air-brushed onto
the surface of the finished nail or fashioned with stencils and fine brushes; however, this
is considered a passing fancy and not part of the mainstream nail technician's daily
routine. Holograms, chagalling, abstract art and graffiti are the latest 'inspirations' for
The condition of the nail may be a function of its aesthetic appeal. The nail may be
softened, or, more frequently, rendered brittle. The brittle nail is vulnerable to single or
multiple longitudinal splitting and horizontal splitting into layers (onychoschizia) or less
often to transverse fractures. Nail fragility requires different kinds of treatment. The
wide variety of techniques employed in treating brittle nails can occasionally be
responsible for some adverse reactions, and these must be added to the total of
unwanted responses to cosmetic procedures. In addition, a sound knowledge of nail
cosmetics as well as a mastery of the instruments used to manicures and nail care are
essential for proper practice.
There are 2 types of coating: the first type of coating (nail varnishes) hardens upon
evaporation; the second type is made of coatings that polymerize. 2
Reactions to nail cosmetic procedures may be divided into reactions at the site of
application to the nail itself and distant reactions, when small amounts of nail
cosmetics are transferred by the hand to other areas of the skin.
Depending on the type of coating some reactions, such as distant allergic contact
dermatitis, are more frequent with nail varnish than with coatings that polymerize. On
the other hand, the latter can cause more damage to the nail than the former.
Ectopic dermatitis, damage in the nail area and the cosmetic hazards (at work,
accidental and infections) will successively be considered.
Ectopic dermatitis (distant contact dermatitis)
The eyelids, the lower half of the face, the sides of the neck, and the upper chest are the
most commonly affected areas. In addition to ectopic dermatitis, allergic airborne
contact dermatitis caused by nail polish ingredients should be suspected when lesions on
the face, neck and ears are symmetrical.
Coatings that polymerize
Technicians, who sculpture nails, should be instructed to wash their hands before
touching the face or eye area. The area most frequently affected is the chin, which
technicians tend to rest in their hands. Additionally, they should be warned to avoid
contact with the dust of freshly applied products and to avoid using the wet product.
Chronic, long-standing localized depigmentation is a unique observation at the site of
positive testing with methacrylates 3
Unreacted UV gel in the dusts and filings may also produce distant allergic reactions. In
this case, technicians should be told to change the light bulbs three times per year and
to apply thinner, multiple coats of products, rather than thicker coats, which are more
difficult to cure. Although sensitization to butyl-hydroxytoluene is possible, gels usually
contain acrylated oligomers and monomers. Acrylates are far more likely to cause
sensitization than methacrylates or stabilizers.
Preformed artificial nails
Allergic reactions due to preformed artificial nails may be indistinguishable from
dermatitis caused by formaldehyde nail hardeners. Ectopic allergic or irritant contact
dermatitis may affect the face and eyelids and large areas of the trunk, and disappear
when the nails are removed. An isolated, chronic, allergic contact dermatitis, simulating
a small plaque of parapsoriasis, caused by cyanoacrylate adhesive used on the
fingernails has also been reported. 4
Damage in the nail area
Dermatitis may affect the periungual area. Nail dystrophy is very rare. Allergic reaction
caused by nail lacquer may be limited to onycholysis. 5
Nail staining from the use of
deeper shades of red and brown nail enamel is most commonly yellow-orange in colour.
Typically, it begins near the cuticle, extends to the top of the nail, and becomes
progressively darker from base to tip. As the varnish continues to leach out, the dyes
penetrate too deeply into the nail to be removed.
Injury to the nail from nail lacquers is rare. However 'granulations' of nail keratin
presenting as superficial friability, can sometimes be observed. In these cases,
individuals continually apply fresh coats of enamel over old ones for periods of weeks.
Granulations are also reported to result from poor formulation of the product.
Coatings that polymerize
Allergic reactions Allergic reactions to sculptured nails may occur 2–4 months, and even
as long as 16 months, after the first application. The first indication is an itch in the nail
bed. Paronychia, which is usually present in allergic reactions, is associated with
excruciating pain in the nail area, and sometimes with paraesthesia. The nail bed is dry,
thickened, and there is usually onycholysis. The natural nail plate becomes thinner, split,
and sometimes discoloured. It takes several months for the nails to return to normal.
Permanent nail loss is exceptional, as is intractable prolonged paraesthesia. 6
Improper application and maintenance With continued wear the edges of the sculptured
nails become loose. These must be clipped and then rebuilt to prevent the development
of an environment prone to bacterial and, beneath the nail plate, candidal infection.
This is a result of improper application and maintenance.
Failure to undergo filing every two weeks will result in the creation of a lever arm that
predisposes to traumatic onycholysis or damage to the natural nail. Onycholysis is very
common with nail extensions that are too long.
Irritant reactions Irritant reactions to monomers are possible. These are manifested as a
thickening of the nail bed's keratin layer, which can sometimes cause the entire nail bed
to thicken with or without onycholysis. Nonetheless, the overwhelming majority of cases
result from physical trauma or abuse.
Damage to the natural nail is not unusual after two to four months of wear of a
sculptured nail. If it becomes yellow or crumbly, this means that the product was applied
and maintained incorrectly. The patient should find a better-qualified nail technician. The
problem may not be the acrylic nail materials but rather the thinning of the nail due to
excessive filing with heavy abrasives.
Primer (methacrylic acid) is a strong irritant, which may produce third-degree burns. It
is hazardous if one floods the cuticles or neglects to wash out spills immediately. One
should not ignore anyone complaining of burning in the nail area, and the affected sites
must be rinsed immediately with water. Primer can permeate the plate and soak into the
nail bed, if the nails are too thin. Soap or baking soda, used with water, are excellent
neutralizers. If primer gets into the eye, it should be flushed with water for at least
15 min, making sure that all traces of the chemical have been rinsed out, and Poison
Control should be called. It must be emphasized that there is a general tendency to
disregard manufacturers' instructions and warnings.
Gel system products are pre-mixed and are either acrylic-based (14% of the market) or
cyanoacrylate-based (1% or less of the market). Their virtual lack of odour makes gels
popular in full-service beauty salons. UV light-cured gels are the best known of the
different gel technologies. These gels contain urethanes and (meth)acrylate compounds,
a photoinitiator and cellulose, which necessitates anti-yellowing agents and a UV light
unit. The gel remains in a semi-liquid form until cured in a photobonding box. The
proportion of resins to monomers determines the gel consistency. When the gel is
exposed to light of an appropriate wavelength, polymerization occurs, resulting in
hardening of the gel. UV gels never use catalysts and often do not use primers.
Gel enhancement products shrink by up to 20%, resulting in lifting, tip cracking and
other types of service breakdown. As an effect of excessive shrinkage, clients may
comment that the enhancement feels tight on the nail bed. Other symptoms include
throbbing or warmth below the nail plate. This may lead to tender, sore fingertips.
Photobonded acrylate has been observed to cause adverse nail reaction, sometimes with
nail loss and paresthesia. Hemmer et al. 7
have patch-tested 'hypoallergenic' commercial
products in patients wearing photobonded acrylic nails who had perionychial and
subungual eczema. Triethyleneglycol dimethacrylate, hydroxyfunctional methacrylates,
and (meth)-acrylated urethanes proved to be relevant allergens in photobonded nail
preparations. Meth-acrylated epoxy resin sensitization was not observed. The omission
of irritant methacrylic acid in UV-curable gels does not reduce the high sensitizing
potential of new acrylates. In contrast to the manufacturers' declaration, all
'hypoallergenic' products continue to include acrylate functional monomers, and
therefore continue to cause allergic sensitization. Gels and acrylics, being chemically
distinct entities, will not necessarily cross-react.
Finally, thick ornately painted gel false nails which may be difficult to remove present a
real challenge to pulse oximetry! 8
Preformed artificial nails
Preformed nails remaining in place for more than three to four days have sometimes
caused onycholysis and nail surface damage. Allergic onychia and paronychia due to
cyanoacrylate nail preparations require some comment. After about three months,
painful paronychia, dystrophy and discoloration of the nails may become apparent and
last for several months. 9
Reaction may be restricted to onycholysis.
Nail cosmetic hazards: accidental and at work
Loss of fingernails due to persisting allergic contact dermatitis in an artificial nail
designer is an unusual hazard produced by an one-component gel. 10
reactions may occur. Six cases of occupational asthma in cosmetologists working with
artificial fingernails due to ethyl methacrylate have been reported. 11
Nail care products are also a common cause of accidental poisoning in children. 12
Although nail enamel is relatively innocuous, the ingestion of enamel removers may
result in acetone intoxication and the ingestion of artificial nail glue removers containing
acetonitrile and nitroethane may cause cyanide poisoning and methemoglobinemia,
respectively. After a latent period of several hours, symptoms of cyanide poisoning may
ensue. Proper diagnosis and management of acetonitrile ingestion, before toxic cyanide
concentrations are reached, can prevent significant toxicity and result in full recovery. 13
The systemic dangers of acrylic fingernails may also be caused by:
Sculptured nail remover solvents which contain acetonitrile and other nitriles resulting in
cyanide production when ingested, 14
and Liquid acrylic monomer associated with N,N-
dimethyl-p.toludine, one of the most potent chemical inducers of methemoglobin.
Ingestion of this chemical results in methemoglobinemia. 15,16
Both necessitate a
different therapeutic approach.
Chemical burns of the airway, gastrointestinal tract, and skin in two children and one
adult after exposure to three different brands of artificial nail primer were observed.
Methacrylic acid was implicated as the offending ingredient. 17
The Consumer Product Safety Commission (CPSC) in the United States now requires
childproof closures on consumer nail products of this type and adequate labelling is
Who applies artificial nails?
In the US, artificial nails have been almost exclusively applied by professionally trained
nail technicians, in salons. It is only in the last three years that artificial nail kits have
become available over the counter. Nevertheless, one should consider that a
professionally-trained technician would be best equipped to apply them and to take the
appropriate precautions into consideration.
Nail cosmetics and infections
It cannot be definitively established that artificial nails or even nail varnish present
absolutely no risk of spreading bacteria, especially considering that perionychial
infection may be associated with sculptured nails. 19
Moreover, a number of potentially
pathological processes associated with the sculptured nail application process and usage
can lead to the development of finger infections. Perionychial trauma often precedes
most paronychia to develop. Cuticle abrasion often occurs during roughening of the
natural nail with a burr prior to sculptured nail application, thus allowing a portal of
entry for invading organisms. Allergic contact dermatitis of the digits related to
sculptured nail acrylic monomers, even hypoallergenic ('acrylate free') products, results
in fissuring and breakdown of the perionychial skin's protective barrier and has been
associated with the development of paronychia. Sculptured nails may also serve as
bacterial repositories, harbouring elevated counts of organisms, thereby increasing the
risk of digit infection and prompting suggestions that healthcare workers should be
especially mindful of this potential source of transmissible disease. Promotion of fungal
and bacterial sculptured nail carriage may be partially related to the increased hydration
of the false nail due to the high permeability of acrylic monomers. 19
The nail plate is also markedly permeable to water. When hands are immersed in liquid
and subsequently removed, water readily evaporates through the nail plate. With the
application of acrylic nails, evaporation of water from the nail plate is impeded, and the
nail plate and bed tend to remain hydrated for prolonged periods. As a result of this
protracted exposure to a damp environment, the nail bed is more likely to separate from
the nail plate and become infected with bacteria and yeast. 20
The longer the nail the more likely it is that bacteria reside under its free edge. Long
nails – both natural and artificial – can facilitate colonization of bacteria on the hands by
making handwashing less effective and the use of gloves less practical. Anecdotal
reports from North America have suggested that nurses who wear acrylic fingernails
may become colonized or infected by Candida and, thus, become a possible risk to
susceptible patients. This possibility remains to be established in clinical practice though
there are theoretical reasons for concern, notably the capacity of Candida to adhere to
acrylic surfaces, as recognized in denture stomatitis. 21
However, in 1982, Nava 22
noted that polished nails pose no risk of infection if they are
manicured and have no chips or cracks. A statement confirmed by Baumgardner et al. 23
who showed that nail polish worn on short, healthy nails does not appear to be
associated with increased microbial counts on the fingernails. Nevertheless, this
contradicts a previous statement that nail polish and rings make hands difficult to
and that 'recommended practices preclude artificial nails'. 25
counts apparently were not affected by the use of different scrub solutions povidone-
iodine, hexachlorophene, and 4% chlorhexidine gluconate solution 26
in the subjects
whose nails were cultured after scrubbing. In addition, it has been shown that fingernail
polish worn longer than four days fosters increased numbers of bacteria on the
fingernails of Operating Room Nurses after surgical hand scrubs. 27
After handwashing, there were higher numbers of colony-forming units of gram-negative
rods cultured from the fingertips of nurses with artificial nails than from those of nurses
with natural nails.* Because of the number of nosocomial infections caused by gram-
negative rods, health care workers who wear artificial nails should consider the
potential risk of increased carriage of gram-negative rods. 28
Certain genera of bacteria,
e.g. Serratia, Acinobacter and Pseudomonas, were recovered only from those nurses
with artificial nails.
More recently, researchers from Oklahoma City 29
found that of 439 infants admitted to
the NICU during the 15-month study period, 46 (11%) acquired P. aeruginosa; 16
(35%) of whom died. Molecular typing confirmed that the genotypes isolated from the
hands of two nurses were the same as those found in 90% of their case patients, and
that these genotypes differed from those found in patients in other parts of the hospital
or in those who arrived in the NICU after the study period. In addition, 92 of the 104
health care workers were assessed for fingernail length and presence of artificial nails.
Those with short- or medium-length nails had a low risk of P. aeruginosa colonization
(one in 80), whereas those with long natural or artificial nails had a significant risk (two
Three case reports of Pseudomonas corneal ulcers following injury to the eye of wearers
of artificial nails have been published. 30
If transmission occurs in one individual, there is
no reason why it cannot occur from person to person. 31
An increased rate of infection
and colonization with P. aeruginosa among infants in neonatal intensive care units
should be investigated by assessing potential reservoirs, including environmental
sources as well as patients and health care workers. 32
Another report also associated artificial nails with fatality. 33
During a one-month period
in 1994, seven cardiac surgery patients at a California hospital acquired postoperative
Serratia marcescens infection, and one died. Researchers identified a scrub nurse as
the likely source of the outbreak. An exfoliant cream she regularly used tested positive
for the strain of S. marcescens that had caused the outbreak. Several controlled studies
show that artificial nails harbour more bacteria than do natural nails. In a 1998 study, a
perioperative nurse manager and clinical nurse specialist, along with her colleagues at St
Luke's Episcopal Hospital in Houston, 34
cultured the nails of 89 operating room staff
members before and after a five-minute surgical scrub. Colonization by Gram-negative
rods was much more common among staff members with artificial nails than among
those with natural nails, both before (44% vs. 16%) and after (37% vs. 6%) the
surgical scrub. The researchers concluded that artificial nails contain more bacteria than
natural nails, placing patients at increased risk for infection.
The Association of Operating Room Nurses (AORN) recommends that artificial nails
should not be worn by operating room personnel, citing reports of fungal and bacterial
infections. In addition, concerns have also been raised by others that the use of
artificial fingernails and nail polish may discourage vigorous handwashing. 35
hospitals have therefore adopted AORN'S guidelines, and some have extended them
beyond the operating theatre, for example, in prohibiting nurses who work in the
neonatal intensive care and labour and delivery units from wearing artificial nails. 36
Some food processing plants have also banned artificial nails and nail polish, to avoid
anything falling into the 'food stream'. A number of occupations and companies now
have policies regarding the maintenance and appearance of their employees' nails.
In conclusion, it can be stated that individuals wearing artificial nails tend to wear their
nails longer and these individuals are more careful about their nails when washing their
hands. This may be related to the cost of artificial nails, whether professionally applied
or self-applied. The sanitary conditions for the application of artificial nails, whether at
the nail salon or at home, are therefore paramount in preventing nail infections. 37
The accuracy of other related reports probably need more careful investigations. These
should be undertaken to reinforce existing procedures for hand-washing by all hospital
personnel. In addition, the 3 mm rule for end-of-fingernail length should be reinforced.
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