What is the procedure for chemical removal of nails, also known as onycholysis (nail removal) or onychomycosis (fungal nail infection) treatment using chemical debridement?

From the Guidelines

Chemical removal of nails is a viable treatment option for fungal nail infections, particularly when combined with antifungal medications like terbinafine or itraconazole, as recommended by the British Association of Dermatologists' guidelines for the management of onychomycosis 2014 1. The most effective treatment for chemical removal of nails involves using keratolytic agents to soften and dissolve the nail plate.

• The medication works by breaking down keratin proteins in the nail, making it soft enough to be scraped away or removed.
• For fungal nail infections, this method is often combined with antifungal medications like terbinafine or itraconazole, which have been shown to be effective in treating onychomycosis, with cure rates of 80–90% for fingernail infection and 70–80% for toenail infection 1.
• The process is painless but requires patience as complete removal can take 1-2 weeks.
• This approach is particularly useful for patients who cannot undergo surgical nail removal due to medical conditions or who prefer a non-invasive option.
• After removal, it's essential to keep the area clean and protected until the new nail grows.
• Chemical nail removal should be performed under medical supervision, especially for diabetic patients or those with peripheral vascular disease, as they have higher risks of complications. The British Association of Dermatologists' guidelines for the management of onychomycosis 2014 recommend terbinafine as the first-line treatment for dermatophyte onychomycosis, with itraconazole as the next best alternative 1.
• Surgical avulsion followed by topical antifungal therapy is not recommended based on the evidence available, and debridement alone cannot be recommended as a treatment for onychomycosis 1.
• Newer devices such as near infrared diode at 870 and 930 nm, and millisecond 1064-nm neodymium-doped yttrium aluminium garnet lasers are showing promising results in the treatment of onychomycosis, but recommendations cannot be made at this stage 1.

From the Research

Chemical Removal of Nails

• Chemical removal of nails can be achieved through various methods, including the use of 40% urea 2
• This method is an alternative to surgical nail avulsion and can be used for diagnostic or therapeutic purposes, such as onychocryptosis, warts, onychomycosis, and chronic paronychia 2
• Chemical removal of nails using 40% urea is a simple and less invasive procedure compared to surgical nail avulsion

Indications for Chemical Removal of Nails

• Onychomycosis: a fungal infection of the nail apparatus that can be treated with oral or topical antifungal agents, including terbinafine 3, 4, 5
• Onychocryptosis: a condition where the nail grows into the surrounding skin, causing pain and inflammation 2
• Warts: a viral infection that can cause lesions on the skin and nails 2
• Chronic paronychia: a condition characterized by inflammation of the nail folds 2

Safety and Efficacy of Chemical Removal of Nails

• The safety and efficacy of chemical removal of nails using 40% urea have not been extensively studied 2
• However, terbinafine, an oral antifungal agent, has been shown to be effective and safe in the treatment of onychomycosis, with a low potential for drug interactions 3, 4, 5
• Topical antifungals are also well tolerated and generally safe, with only potential local side effects 6