Nail health can be a mirror of overall health. For example, Muehrcke’s lines (horizontal bands of nail discoloration) are typically caused by low serum albumin. Nail clubbing, which develops over years, is associated with low oxygen in the blood and has been described in patients suffering from severe gastrointestinal disorders, cardiovascular disease, and immune dysfunction. Koilonychia, a spoon-like depression of the nail bed, may indicate hypochromic anemia or other disruptions of iron absorption. Beau’s lines, indentations that run across the nail, can be a sign of trauma but can also be a sign of zinc deficiency. Finally, nail pitting, scaling, and thickening is common to psoriasis involving the nails and can accompany onychomycosis, or fungal infection of the nail.


Psoriatic nail disease generally occurs in patients with cutaneous psoriasis; however, it can rarely (5%) be seen in the absence of clinically evident psoriasis of the skin. Nail psoriasis can be treated using compounded topical agents and treatment may include an antifungal component since nail psoriasis and fungal nail infections are often comorbid conditions. Medications typically found in compounded nail psoriasis therapy include fluorouracil, glucocorticoids and/or vitamin D3 analogues. These agents can be compounded into creams, ointments, and gels. A study which included 48 patients, tested the efficacy of a preparation containing calcipotriol and clobetasol propionate in the treatment of nail psoriasis. After a year of treatment, nail thickness was reduced by 81.2% and 72.5% in finger and toe nails, respectively.

In the case of recalcitrant onychomycosis, a multi-drug approach to treatment has been studied and used with success. Compounded preparations can include a potent antifungal agent paired with other agents and applied directly to the nail. One study looked at the effects of combining butenafine, a potent antimitotic fungicidal, with tea tree oil, known to have antiseptic and antifungal properties, in a cream base for the treatment of onychomycosis. In this study, 60 patients were randomized to treatment with a compounded topical agent or placebo. After 16 weeks of therapy, 80% of patients in the treatment group were cured compared to zero patients in the placebo group. Another study looked at a combination of fluconazole, along with the emollient urea, compounded into a nail lacquer. In this study of 70 patients, treatment was well tolerated and had an 82.8% cure rate.

Topical preparations are the preferred route of treatment of nail disorders due to the relatively toxic effects of systemic therapy. Since treatment can be prolonged, oral regimens may require regular side effect monitoring and may even interact with other oral medications; elderly patients with comorbidities are particularly at risk for experiencing adverse effects and drug interactions from oral therapy. Generally, it’s important to use a combination of medications to promote healing and prevent nail disorder relapse.


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