Here. A 70-year-old diabetic woman with hallux valgus presented with stasis dermatitis and a 20-year history of severe thickening, abnormal growth and yellow discolouration of the toes becoming painful, making it difficult to walk and put on socks. There was no history of trauma, or family history of onychomycosis. Physical examination found a thicker, longer, curved, circular cross-sectional nail plate resembling a claw surrounded on the right big toe by erosion topped by yellowish crusting with diffuse xanthonychia of the toes (Figs. 1a and 1b). The patient was treated with antibiotic therapy and a surgical avulsion with matrix phenolisation was performed (Figs. 1c and 1d).

Figure. 1: (a) Onychogryphosis with irritant dermatitis. (b) Mechanical avulsion of the big toe. (c) Phenolisation after surgical avulsion. (d) Appearance of the nail bed after total avulsion of the onychogryphosis.

Acquired onychogryphosis is most commonly seen in elderly people who have been poorly cared for or with impaired peripheral circulation, including varicose veins, stasis dermatitis and lower leg ulcers as well as microtrauma most often due to ill-fitting footwear, and foot abnormalities, such as hallux valgus [1] as was the case in our patient. In a study done in Tokyo [2] the prevalence is higher in the elderly population at 17.9%. The diagnosis is clinical based on the characteristic appearance associating thickening of the nail plate with macroscopic hyperkeratosis and increased curvature giving a ram’s horn appearance. The disorder may be clinically confused with or associated with onychomycosis, and therefore fungal studies are necessary.

Treatment, whether palliative or operative, is warranted to prevent complications and also for aesthetics. It is based on the avoidance of excessive pressure on the nail bed and trauma [3].

Conservative methods are preferred in the elderly population, especially in patients with comorbidities, but if the method fails and the patient is symptomatic, the definitive treatment is nail avulsion followed by matrixctomy. Matrix phenolisation is more effective and practical with a favorable outcome as in our patient’s case.

REFERENCES

Notes

1. Chang P, Domínguez K. [Nail diseases in elderly. Report of 71 cases]. Our Dermatol Online. 2016;7:385-90.

2. Barkhordari K, Shafiee A:Ram’s horn nail in lower-limb ischemia. J Tehran Heart Cent 2015;10:163–4.

3. Talwar A, Puri N. A study on the surgical treatment of ingrowing toe nail with nail excision with chemical matricectomy versus nail excision alone. Our Dermatol Online. 2013;4:32-4.