What is the topical treatment for erythema of the proximal nail fold, absence of cuticle, nail plate thickening, and marked horizontal ridges, suggestive of onychauxis (nail thickening) and Beau's lines (horizontal ridges)?

From the Guidelines

For the treatment of erythema of the proximal nail fold with absent cuticle and thickened nail plate with horizontal ridges, I recommend a combination approach, starting with a topical corticosteroid such as clobetasol 0.05% ointment applied to the affected nail fold twice daily for 2-3 weeks, as this approach has been shown to be effective in managing similar conditions 1. This should be combined with an antifungal cream like ketoconazole 2% or ciclopirox 8% applied once daily for 4-6 weeks, as these symptoms often indicate paronychia with possible fungal involvement.

• Soak the affected nail in warm water with antiseptic solution for 10-15 minutes daily before applying medications.
• Avoid trauma to the area, keep nails short, and don't manipulate the cuticle. For the horizontal ridges (Beau's lines), they typically grow out over time as the nail plate regenerates. The inflammation response in the nail matrix disrupts normal nail formation, causing these ridges. If symptoms don't improve within 2-3 weeks or worsen, consult a dermatologist as oral antifungals or antibiotics may be necessary, especially if the condition is chronic or severe, as suggested by the management guidelines for paronychia 1. It's also important to note that while amorolfine has been shown to be effective in treating onychomycosis 1, the primary concern here is the erythema and inflammation of the proximal nail fold, which requires a different approach. Therefore, the focus should be on reducing inflammation and preventing infection, rather than solely treating a potential fungal infection.

From the FDA Drug Label

Apply Urea 40% to affected skin twice per day, or as directed by your physician. Rub in until completely absorbed. Apply to diseased or damaged nail(s) twice per day, or as directed by a physician. The topical treatment for erythema of the proximal nail fold and absence of cuticle nail plate thickened and marked horizontal ridges is Urea 40% applied to the affected area twice per day, or as directed by a physician 2.

• Key points:
  • Apply to affected skin and diseased or damaged nail(s)
  • Apply twice per day
  • Rub in until completely absorbed

From the Research

Topical Treatment for Erythema of the Proximal Nail Fold

• The condition described, erythema of the proximal nail fold, absence of cuticle, nail plate thickened, and marked horizontal ridges, suggests a possible diagnosis of paronychia, which is a common disease affecting the hand 3.
• Paronychia can be complicated by Candida spp or bacterial infections, and general preventive measures can be useful in maintaining health 3.
• A study published in 2015 investigated the efficacy and tolerability of a new combination of topical medications in the treatment and prevention of moderate and chronic paronychia, which included an insulating polymer, two topical antifungals, and a molecule with anti-inflammatory activity 3.
• The results of this study showed that 26 patients responded to therapy, with a clinical cure in 46.6% of patients, improvement in 40%, and failure in 13.4% 3.

Treatment Options

• Topical antifungal agents are generally successful in treating superficial fungal infections, unless the infection covers an extensive area or is resistant to initial therapy 4.
• The presence of inflammation may necessitate the use of an agent with inherent anti-inflammatory properties or the use of a combination antifungal/steroid agent 4.
• However, the use of combination antifungal/corticosteroid agents may be associated with persistent or recurrent infection, as seen in a study of children with tinea corporis 5.
• Oral antifungal agents, such as itraconazole and terbinafine, may be effective in treating fungal nail infections, but limited data exist on their use in immunocompromised patients 6.

Expert Recommendations

• An expert panel meeting on the topical treatment of superficial mycoses concluded that the treatment should be tailored to the individual needs of the patient, taking into account the type, location, and surface area of the infection, patient age, degree of inflammation, and underlying comorbidities 7.
• The addition of a corticosteroid to an antifungal agent at the initiation of treatment can attenuate the inflammatory symptoms of the infection and increase patient compliance, but incorrect use of antifungal-corticosteroid therapy may be associated with treatment failure and adverse effects 7.