what to do about a split toenail on little toe

• Journal List
• Skin Appendage Disord
• v.1(4); 2016 May
• PMC4908446

Skin Appendage Disord. 2016 May; 1(4): 163–167.

Double Smash of the Piffling Toe

Received 2015 November 25; Accepted 2015 Dec 14.

Abstruse

A rudimentary accompaniment or double boom of the little toe is not rare, although only described iii times before. Near cases are accidentally detected and just few patients seek help because they have discomfort or pain. Some have a positive family history, simply well-nigh patients cannot requite any information concerning heredity. Clinically, the nail of the piffling toe is abnormally wide and is carve up or shows a longitudinal depression corresponding to a slight protuberance of the cuticle. Histopathology shows a complete though brusque nail. The treatment of choice is segmental excision of the entire accessory nail unit of measurement with mobilization of the lateral peel and primary suture.

Central Words: Picayune toenail, Double nail, Accessory nail, Nail unit resection, Histology

Introduction

Modern civilization has resulted in poor pes health with many painful conditions and caused malformations. These are often taken for granted past the affected individuals until they cause discomfort and pain. Often, one condition leads to another and they mutually beal each other. Apartment and splayfoot are extremely mutual leading to callus formation in the middle of the forefoot sole, hallux valgus and external rotation of the little toe. Some patients develop a callus or even a corn on the lateral aspect of the little toe that may become painful, particularly when wearing pointed shoes.

In the concluding xx years, many patients who had a callus on the lateral attribute of the distal phalanx of the little toe and a peculiar wide picayune toenail with a dissever betwixt the lateral and median tertiary were incidentally seen.

Materials and Methods

The writer'south photographic annal from April 2000 until Oct 2013 was searched for the diagnosis of 'double nail' or 'double little toenail'. The charts of the patients seen subsequently 2005 were retrieved and evaluated for gender, age, nationality, race, familiarity and treatment. Surgery, either excision or phenolization, was recommended for symptomatic cases. All surgical specimens were examined histopathologically with hematoxylin and eosin and PAS stains. Immunohistochemistry was performed in three cases.

Results

Patients with double little toenails were seen in all countries visited, irrespective of skin complexion and race (table ​ ane). Most cases were detected during an test for another reason, some patients showed their fiddling toes during human foot examination, and only very few consulted because of this condition.

Table 1

Patients with double little toenails co-ordinate to twelvemonth of diagnosis, gender, age at diagnosis, nationality and affected side

Patient	Year	Gender	Age, years	Nationality	Side
TG	2000	F	57	Norwegian	both
NEM	2001	F	47	Norwegian	both
DN	2001	F	42	Norwegian	both
DKZ	2002	F	53	Norwegian	both
HDN	2002	F	49	Norwegian	both
HM	2003	F	37	Norwegian	both
JGM2003	2003	F	42	Norwegian	both
WK	2003	Yard	43	Norwegian	both
GAB	2003	F	45	Norwegian	both
GDN	2004	K	35	Ghanaian	both
GAM	2005	F	65	German	both
CH	2006	One thousand	lx	German	both
DKN	2006	F	38	German	both
DPN	2006	F	42	German	both
HL	2007	M	3 i/2	German	both
FP	2007	G	31	Polish	both
HDB	2008	Thou	42	Swiss	both
FA	2008	F	41	Italian	both
SB	2008	F	28	German language	both
BN	2009	Chiliad	62	Swiss	both
DAB	2009	M	38	Swiss	both
SE	2009	F	37	Swiss	both
GP	2009	One thousand	16	Swiss	both
GM	2009	F	threescore	Swiss	both
RS	2009	F	58	German	left
PG	2009	F	65	German	both
MT	2009	F	59	German	both
WM	2009	M	49	German	both
GD	2009	F	32	Mexican	both
DR	2009	F	28	Swiss	both
FR	2009	F	53	High german	both
JWB	2009	F	42	Swiss	both
AW	2009	F	52	Swiss	both
					(r > 1)
GP	2010	F	35	Swiss	both
TN	2010	M	5 i/2	Indian	both
BAMMM	2010	F	36	Portuguese	both
BBM	2010	F	twoscore	Swiss	both
BV	2011	F	59	Swiss	left
GP	2011	M	23	Swiss	both
MB	2011	Yard	43	Belgian	both
CMAC	2011	F	68	Portuguese	both
BKK	2012	F	47	Thai	both
BKT	2012	F	61	Thai	both
MD	2012	F	xiii	Swiss	both
SA	2012	F	60	Swiss	both
SD	2012	M	13	Swiss	both
SA	2012	F	22	Swiss	both
SA	2012	F	48	Swiss	both
BT	2013	F	9	Swiss	correct
JH	2013	F	45	German	both
SN	2013	M	68	Turkish	both
CL	2013	F	21	Swiss	both
CW	2013	M	48	Han Chinese	both
HD	2013	M	52	High german	both
NS	2013	M	62	Tamil	left
BB	2013	F	53	Swiss	left
ZJ	2013	F	36	Swiss	both
DMWC	2013	K	51	Belgian	both

The age of the patients ranged from v to 68 years; those individuals that were enlightened of their condition stated that their toes had always been like this or that they could not remember when it had started. Familial occurrence was only seen when the patient was accompanied by a family member, except for 2 patients with symptomatic double nails who reported that their father and grandfather, or mother and aunt, respectively, too had the same condition.

Clinically, a broad trivial nail was by far the commonest presentation (fig. ​ 1, ​ ii). Close inspection and dermatoscopy revealed that the boom consisted of two parts with the medial being bigger than the lateral one. They were divided past a longitudinal depression or a real divide and the cuticle protruded slightly distally in this item location. Ii really singled-out nails were rare (fig. ​ 3, ​ 4). The expression was usually symmetrical on both sides, although roughly one quaternary showed a more marked picture on one side.

Niggling toes with double nail in a 36-year-old Portuguese woman. Note the callus at the lateral side of the heart interphalangeal articulation.

Both little toes with double nails in a 52-twelvemonth-quondam Swiss woman who consulted u.s. for retronychia.

Asymmetric expression of the double petty toenails: two private correct toenails and the typical left double nail adjacent to the main nail.

A 39-yr-sometime Swiss woman with bilateral double fifth toenails. The left little toe before segmental excision and iv weeks afterwards surgery is shown.

Discomfort was noted past approximately ane 3rd and pain by i 5th of the, mostly elderly, patients. Near of them had a splayfoot with external rotation of the petty toe, with an nigh vertically growing nail exerting pain (fig. ​ five). They too often had a circumscribed callus lateral to the nail (fig. ​ 1), which was ordinarily misdiagnosed as a hard corn. Palpation and probing showed that it was the nail, non the callus, that was painful. A radiograph was taken in 10 patients; however, the quality of the X-ray films of the little toe did usually not let specific details to be detected. Three patients exhibited a lazy Y at the tip of the distal phalanx and one a thorn-like bony excrescence. In two patients, a Y-shaped tip of the final phalangeal bone was identified during surgery.

Schematic illustration of the evolution of a symptomatic double toe and its treatment. a Patients with a splayfoot develop both a hallux valgus with internal likewise as external rotation of the fiddling toe. b Outward rotation makes the toenail beingness almost vertically positioned thus exerting symptoms like to a corn upon pressure. c The excision line is drawn for the complete segmental removal of the accompaniment nail. Similar in the big toenail, the lateral matrix horn reaches far proximal-laterally. d After the extirpation of the accompaniment nail, a little toenail of normal width is created.

Most patients did not request treatment. However, for those who accustomed treatment, either phenolization of the accessory matrix or complete resection of the double smash was performed. Healing was uneventful in all cases, taking about 10 days for the surgical excision and three weeks for the chemocautery. Normal physical activity was taken up ii-3 days subsequently phenolization (fig. ​ 6, ​ vii).

Double nail of the left fifth toe earlier and 3 weeks subsequently surgical resection of the accessory role of the blast.

Double nail of the left petty toe before and 8 days later phenolization of the accessory blast.

Differential diagnosis comprises traumatic double blast, ectopic blast and smash spiculum subsequently incomplete extirpation of the lateral matrix horn. Histologic examination of the surgical specimens showed virtually all components of a normal blast in the most pronounced cases and only an invagination of a thick hyperkeratotic epidermis with a broad stratum granulosum and a narrow cone of typical nail plate in the heart in small double nails (fig. ​ eight). There were all transitions in between these 2 extremes. The fully developed double nail had a normal or moderately thickened matrix epithelium and a normal though brusque nail bed with a disproportionately long isthmus. The hyponychium was clearly discernable. The proximal blast fold was well adult, with a relatively thick cuticle and a pronounced true and false eponychium. Fungal elements were seen in PAS-stained sections in i patient. Immunohistochemistry showed a CD10-positive onychodermis and a weaker CD34 positivity in the matrix and proximal nail bed dermis. Glomus bodies and neural structures were seen as in normal nails.

Histopathology of a poorly developed double smash (left) shows a shallow depression of the epidermis with eosinophilic hyperkeratosis and a pale area in the heart representing nail substance, whereas a well-developed double smash (right) shows all characteristics of a normal piffling toenail with proximal nail fold and thick cuticle, matrix and very short but hyperplastic nail bed.

Discussion

A hereditary dysplasia of the fifth toenail identical to our observations was first published in 1969 [1]. Surprisingly, descriptions of a double piffling toenail are rare [2,3], despite its relatively common occurrence. It was thought to be a feature of Han Chinese [3], but amidst our patients, in that location was just one Han Chinese colleague who showed his feet during an observational phase. Notwithstanding, double little toenails were observed in dermatological practices in Deutschland, Norway, the Netherlands, Switzerland, Belgium, Portugal, and Thailand besides equally in immigrants from a variety of other countries including Africa (Benin). Thus, this is certainly not a special racial or ethnic feature, although it has to exist stated that our results exercise not allow conclusions to exist drawn as to the frequency of double lilliputian toenails in dissimilar countries, continents and races.

Although rarely stated, the condition appears to be autosomal dominant and occurring in families, both in males and in females. In our study, women predominated, simply this is probably due to the fact that they have more oftentimes acquired foot bug and wear narrow pointed stylish shoes. Ii mothers came with their healthy children, ane daughter and ane son, who both had hitherto unnoticed asymptomatic double trivial toenails like their mothers. However, the expression was variable; whether this is a genetically variable expression or merely due to the age is not clear. Equally well-nigh patients did not fifty-fifty mention their double trivial toenails, it tin can be assumed that they are non embarrassed by them. In our cases, they were between 2 and seven mm wide. Symptoms did not necessarily depend on the width of the nail but rather on the severity of accompanying pes anomalies.

Handling, if requested, is easy. We either performed a selective matrix phenolization using 88% liquefied phenol for a full of three times for 1 min nether consummate anemia with a tourniquet or past segmental excision of the accessory nail including the entire double nail with the matrix, proximal fold and hyponychium. The defect was closed primarily with triple sutures after mobilization of the lateral attribute of the distal phalanx. Triple sutures allow v-0 suture material to be used equally much of the tension is exerted and distributed while tying a single knot.

Pathomechanisms and genetics are interesting aspects to be considered. Fully developed supernumerary digits develop nails. Information technology is known that a bone core has to exist nowadays at the distal phalanx for the evolution of a smash anlage; atelephalangia is associated with lack of nail germination or blast hypoplasia [4,five], although total complete anonychia also occurs without bone changes [half dozen]. Whether or not an additional bone core, which may exist institute in the bifid tip of the distal phalanx of the little toe, is sufficient to induce an accessory nail remains a matter of speculation at this moment. On the other mitt, blast epithelium also has a special office in os formation and digit regeneration. Boom cells were indeed found to influence underlying mesenchymal cells to regenerate digit bone [7].

Another interesting question is how this condition develops. Whether the double little toenail represents the most initial form of a hexadactyly has not been investigated. If information technology is a rudimentary hexadactyly, information technology may induce an actress blast anlage. One patient stated that a radiograph taken for a hallux valgus operation had shown a spine-like extension at the lateral aspect of the terminal phalanx of the petty toe. Hexadactyly is sometimes hereditary [8]. Some other interesting point is that in congenital onychodysplasia of the alphabetize finger (Iso-Kikuchi syndrome), also known equally COIF, a Y-shaped distal phalanx of the index finger is associated with a defective index nail, such as hemimicronychia and several other types of onychodysplasia [9,10].

In conclusion, a double or accompaniment little toenail is a rather common though underdiagnosed and rarely reported condition. Information technology is autosomal dominant with variable expression. Symptoms such as hurting and discomfort are infrequent. Histological examination of these double piddling toenails shows curt simply otherwise normal nails or less well developed nail structures.

Argument of Ideals

The study was performed in accordance with the Helsinki Announcement and Skilful Clinical Practice.

Disclosure Argument

The authors have no conflicts of interest to disclose.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4908446/

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