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  • 1. 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. doi:10.1046/j.1473-2130.2001.00017.x Prev Article Next Article Full Text 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: baran.r@club-internet.fr *The length of artificial versus natural nails is not mentioned in the article. Keywords : artificial nails, systemic danger, bacterial and fungal infection Abstract Summary 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 infections. Introduction
  • 2. Our present concept of nail beauty depends on the shape of the nail, its texture and its decoration 1 . 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 nail artists. 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.
  • 3. Ectopic dermatitis (distant contact dermatitis) Nail polish 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 Sculptured nails 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 . Gels 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
  • 4. Nail polish 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 Sculptured nails 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
  • 5. 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. Gels 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.
  • 6. 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 Professional hazards 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 Systemic adverse reactions may occur. Six cases of occupational asthma in cosmetologists working with artificial fingernails due to ethyl methacrylate have been reported. 11 Accidental hazards 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.
  • 7. 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 mandatory. 18 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
  • 8. 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 decontaminate 24 and that 'recommended practices preclude artificial nails'. 25 Bacterial 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
  • 9. (one in 80), whereas those with long natural or artificial nails had a significant risk (two in 12). 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 Many 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. Conclusion
  • 10. 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. 37 References 1 Baran R , Schoon D. Cosmetology for nails. In: R Baran , H Maibach eds. Textbook of Cosmetic Dermatology, 2nd edn. London : Martin Dunitz; 1998: pp. 55–1050. 2 Schoon D. Milady's nail structure and product chemistry. Albany, NY : Milady/Delmar Publishing; 1996. 3 Casse V , Salmon-Her V , Mohn C , Kalis B. Dépigmentation durable secondaire à des tests positifs aux dérivés des méthacrylates. Ann Dermatol Venereol 1998; 125: 56–57. Medline, ISI 4 Shelley ED , Shelley WV. Chronic dermatitis simulating small-plaque parapsoriasis due to cyano- acrylate adhesive used of fingernails. J Am Medical Assoc 1984; 252: 2455–6. CrossRef, Medline, ISI 5 Guin JD , Wilson P. Onycholysis from nail lacquer: a complication of nail enhancement? Am J of Contact Dermatitis 1999; 10: 34–36. Medline
  • 11. 6 Fisher AA , Baran R. Occupational nail disorders with a reference to Koebner's phenomenon. Am J Contact Dermatitis 1992; 3: 16–23. 7 Hemmer W , Focke M , Wantke F , et al. Allergic contact dermatitis to artificial fingernails prepared from UV light-cured acrylates. J Am Acad Dermatol 1996; 35: 377–80. CrossRef, Medline, ISI 8 Ashley E , Marshall P. Problems with fashion. Anaesthesia 2000; 55: 811–834. 9 Kanerva L , Estlander T . Allergic onycholysis and paronychia caused by cyanoacrylate nail glue, but not by photobonded methacrylate nails. Eur J Dermatol 1999; 9: 223–5. Medline 10 Halgmüller T , Hemmer W , Kusak I , et al. Loss of fingernails due to persisting allergic contact dermatitis in an artificial nail designer. J Allergy Clin Immunol 1995; 95: 250. 11 Spencer AB , Estill CF , McCammon JB , Mickelsen RL , Johnston OE. Control of Ethyl Methacrylate exposures during the application of artificial fingernails. AIHA Journal 1997; 58: 214–218. CrossRef 12 Litovitz T , Manoguerra A. Comparison of paediatric poisoning hazards: an analysis of 3.8 million exposure incidents. Pediatrics 1992; 89: 999–1006. Medline, ISI 13 Rainey PM , Roberts WL. Diagnosis and misdiagnosis of poisoning with cyanide precursor acetonitrile: nail polish remover or nail glue remover? Am J Emerg Medical 1993; 11: 104–8. Medline, ISI 14 Kurt TL , Day LC , Reed WS , Gandy W. Cyanide poisoning from sculpted nail remover. Vet Hum Toxicol 1989; 31: 339. Medline 15
  • 12. Potter JL , Krill CE , Neal D , Kofron WG. Methemoglobinemia due to ingestion of N,N-Dimethyl-p- Toluidine, a component used in the fabrication of artificial fingernails. Ann Emerg Medical 1988; 17: 1098–1100. Medline, ISI 16 Kao L , Leikin JB , Crockett M , Burda A. Methemoglobinemia from artificial fingernail solution. JAMA 1997; 278: 549–550. Medline, ISI 17 Linden CH , Scudder DW , Dowsett RP , Liebelt EL , Woolf AD. Corrosive injury from methacrylic acid in artificial nail primers: another hazard of fingernail products. Pediatrics 1998: 102: 979–84. Medline, ISI 18 Woolf AD , Shaw JS. Nail primer cosmetics: correlations between product pH and adequacy of labelling. J Toxicol Clin Toxicol 1999; 37: 827–832. CrossRef, Medline, ISI 19 Roberge RJ , Weinstein D , Thimons MM. Perionychial infections associated with sculptured nails. Am J Emerg Medical 1999; 17: 581–582. CrossRef, Medline, ISI 20 Kechijian P. Dangers of Acrylic Fingernails. JAMA 1990; 263: 458. ISI 21 Symonds J , O'Dell CA. Candida nail bed infection and cosmetic acrylic nail extension – a potential source of hospital infection? J Hosp Infect 1993; 23: 243–7. Medline, ISI 22 Nava S. Removing rings, washing hands necessary in family centred GB ward. Hosp Infect Control 1982; 9: 168. 23 Baumgardner CA , Maragos CS , Walz JA , Larson E. Effects of nail polish on microbial growth of fingernails. AORN J 1993; 58: 84–8. Medline
  • 13. 24 Bennet JV , Brachman PS. Hospital infections. Boston : Little, Brown & Co; 1979: 89. 25 Ricards J. Recommended practices preclude artificial nails. AORN J 1985; 42: 793. 26 Rubin DH. Prosthetic fingernails in the OR: a research study. AORN J 1988; 74: 944–946. Medline 27 Wynd CA , Samstag DE , Lapp AM. Bacterial carriage on the fingernails of OR nurses. AORN J 1994; 60: 796–805. Medline 28 Pottinger J , Burns S , Manske C. Bacterial carriage by artificial vs. natural nails. Am J Infect Control 1989; 17: 340–344. Medline, ISI 29 Winslow EH , Jacobson AF. Can a fashion statement harm the patient? AJN 2000; 100: 63–5. 30 Parker AV , Cohen EJ , Arentsen JJ. Pseudomonas corneal ulcers after artificial fingernails injuries. Am J Ophtalmol 1989; 107: 548–9. Medline, ISI 31 Senay H. Acrylic nails and transmission of infection. Can J Infect Control 1991; 6: 52. Medline 32 Foca M , Jakob K , Whittier S , et al. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 2000; 343: 695–700. CrossRef, Medline, ISI 33
  • 14. Passaro DJ , Waring L , Armstrong R , et al. Postoperative Servatia marcescens traced to an out of hospital source. J Infect Dis 1997; 175: 992–995. Medline, ISI, CSA 34 Edel E , Houston S , Kemedy V , LaRococco M. Impact of a 5-minute scrub on the microbia flora found on artificial, polished, or natural fingernails of operating room personnel. Nursing Research 1998; 47: 54–59. Medline, ISI 35 Larson E , Lusk E. Evaluating handwashing technique. J Adv Nursing 1985; 10: 547–552. Synergy, Medline, ISI 36 Hill S. Outlawed nails. Nails Magazine 1998; 8: 56–61. 37 Jackson EM. Some hospitals ban artificial nails. Cosmetic Dermatol 2001; 14: 52–53. This article is cited by: • Robert Baran & Josette André. (2005) Side effects of nail cosmetics. Journal of Cosmetic Dermatology 4:3, 204–209 Abstract Abstract and References Full Text Article Full Article PDF • Josette André. (2005) Artificial nails and psoriasis. Journal of Cosmetic Dermatology 4:2, 103–106 Abstract Abstract and References Full Text Article Full Article PDF • Robert Baran. (2002) Nail Cosmetics. American Journal of Clinical Dermatology 3:8, 547 CrossRef

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