What are the treatment options for ridged nails?

Treatment Options for Ridged Nails

The first step in treating ridged nails is to determine the underlying cause through laboratory diagnosis, as 50% of nail dystrophy cases are fungal in origin and require specific antifungal treatment. 1

Diagnostic Approach

• Laboratory diagnosis should be performed before initiating treatment, consisting of microscopy to visualize fungal elements and culture to identify the specific pathogen 1
• Samples should be collected from the most proximal part of the infection, as dermatophyte onychomycosis primarily affects the nail bed rather than the nail plate 1
• Direct microscopy and fungal culture should be performed by experienced professionals to avoid misdiagnosis 1

Treatment Options Based on Etiology

For Fungal Infection (Onychomycosis)

• First-line oral treatments:

  • Terbinafine: 250 mg daily for 6 weeks in fingernail and 12-16 weeks in toenail infections (preferred over itraconazole for dermatophyte infections) 1
  • Itraconazole: 200 mg daily for 12 weeks continuously or as pulse therapy at 400 mg daily for 1 week per month (2 pulses for fingernails, 3 for toenails) 1

• Alternative oral treatments:

  • Fluconazole: 150-450 mg weekly for 3 months in fingernail infections and at least 6 months in toenail infections 1
  • Griseofulvin: 500-1000 mg daily for 6-9 months in fingernail infection and 12-18 months in toenail infection (less effective with higher relapse rates) 1

• Topical treatments:

  • Amorolfine 5% lacquer: Applied once or twice weekly for 6-12 months (useful for superficial and distal onychomycosis) 1
  • Ciclopirox 8% lacquer: Applied once daily for up to 48 weeks 1
  • Tioconazole 28% solution: Applied twice daily for 6-12 months 1

For Inflammatory Conditions (e.g., Nail Psoriasis)

• Topical treatments:

  • Mid to high-potency topical steroid ointment applied to nail folds twice daily to reduce inflammation 2
  • Daily antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 2

• Systemic treatments for severe nail psoriasis:

  • Anti-TNF-α, anti-IL-17, and anti-IL-12/23 antibodies are highly effective for nail psoriasis when associated with severe cutaneous disease 3

For Brittle Nails and Environmental Damage

• Regular application of emollients to cuticles and periungual tissues to maintain skin barrier function 2
• Avoid repeated trauma by wearing comfortable well-fitting shoes and protective gloves when working with water or chemicals 2
• Keep nails trimmed short and cut straight across 2
• Avoid cutting cuticles or manipulating the nail folds 2
• Maintain good hand hygiene and avoid artificial nails and harsh nail products 2

Prevention of Recurrence

• For fungal infections, emphasize the importance of wearing protective footwear in public bathing facilities 1
• Apply absorbent powder and antifungal powders containing miconazole, clotrimazole, or tolnaftate in shoes and on feet 1
• Wear cotton, absorbent socks and keep nails short 1
• Consider treating all infected family members simultaneously as onychomycosis is contagious 1
• Discard old footwear or disinfect shoes using naphthalene mothballs in tightly tied plastic bags for at least 3 days 1

Common Pitfalls and Caveats

• The most common cause of treatment failure for onychomycosis in the UK is incorrect diagnosis made on clinical grounds alone 1
• Successful eradication of fungus does not always restore nails to normal appearance if they were dystrophic prior to infection 1
• Mycological cure rates are typically about 30% better than clinical cure rates in most studies 1
• For treatment failures, consider poor compliance, poor absorption, immunosuppression, dermatophyte resistance, or zero nail growth as potential causes 4
• Systemic therapy for onychomycosis carries risks of adverse effects and should be used with caution when benefits outweigh risks 5

Remember that nail disorders are not merely cosmetic concerns but can significantly impair daily activities and reduce quality of life if left untreated 6. Proper diagnosis is essential as nail changes may also indicate underlying systemic diseases 6.