What is the best approach to manage and improve chipping nails in a patient, including workup and treatment options?

Management of Chipping Nails: Workup and Treatment

Initial Assessment and Workup

The first priority is to distinguish between primary idiopathic brittle nail syndrome and secondary causes through targeted history and examination, as this fundamentally changes management.

Key Historical Elements to Obtain

• Document occupational and environmental exposures, particularly repetitive water immersion, chemical exposure, and mechanical trauma, as these are the most common reversible causes of nail brittleness 1, 2.
• Screen for systemic diseases including thyroid dysfunction (onycholysis suggests hyperthyroidism), anemia or hemochromatosis (koilonychia/"spoon nails"), inflammatory bowel disease (clubbing), and connective tissue disorders (telangiectasia, pitting) 3.
• Review current medications, particularly chemotherapy agents and EGFR inhibitors, which can cause drug-induced nail toxicity 4.
• Assess nutritional status and dietary habits, focusing on protein intake and potential deficiencies in biotin, iron, or other micronutrients 1, 2.

Physical Examination Findings

• Identify the specific pattern of brittleness: onychoschizia (horizontal splitting/lamellar splitting), onychorrhexis (longitudinal ridging/splitting), or superficial granulation 2.
• Examine for signs of fungal infection (subungual hyperkeratosis, discoloration, friability) which requires mycological confirmation before treatment 4.
• Look for inflammatory nail disease patterns such as psoriatic nail pitting, oil spots, or lichen planus changes (thinning, pterygium) 4.

Laboratory Workup When Indicated

• Order complete blood count, iron studies, and thyroid function tests if systemic disease is suspected based on clinical presentation 3.
• Obtain fungal culture and direct microscopy if onychomycosis is suspected—this is essential before initiating antifungal therapy 4.
• Check albumin levels if Muehrcke's lines are present 3.

Treatment Algorithm

First-Line Conservative Management (All Patients)

Begin with protective measures and topical therapy, as these address the most common causes and have no adverse effects.

Environmental Protection

• Keep hands and feet as dry as possible; avoid prolonged soaking in soapy water without adequate protection (wear cotton gloves under washing gloves) 4.
• Minimize nail trauma by wearing properly fitted shoes with rounded toe boxes, firm support, and breathable materials 4.
• Apply hypoallergenic moisturizers and emollients daily to prevent progressive dehydration of the nail plate 4, 1.

Proper Nail Care Technique

• Trim nails straight across using clean instruments to prevent splitting and catching 4, 5.
• File nail surfaces gently with an emery board after softening in warm water or saline soaks to smooth rough edges 4, 5.
• Apply urea-based keratolytic cream (10-40% concentration) daily to weekly to soften and moisturize the nail plate 4, 5.
• Avoid excessive filing or aggressive trimming, which further damages fragile nails 5.

Second-Line: Oral Supplementation (Idiopathic Cases)

If conservative measures fail after 2-3 months and secondary causes are excluded, initiate biotin supplementation, which has the strongest evidence for efficacy.

• Prescribe biotin 2.5 mg daily for a minimum of 5-6 months, as 91% of patients show definite improvement with firmer, harder nails 6, 2, 7.
• Consider silicon supplementation (10 mg daily of choline-stabilized orthosilicic acid) as an alternative, though evidence is less robust than for biotin 7.
• Note that vitamin E, vitamin C, vitamin A, zinc, iron, copper, selenium, and vitamin B12 have no proven benefit for nail health in well-nourished patients 7.

Treatment of Secondary Causes

Fungal Infection (Onychomycosis)

• For dermatophyte infection, prescribe terbinafine 250 mg daily for 6 weeks (fingernails) or 12-16 weeks (toenails) as first-line systemic therapy, with baseline liver function tests and complete blood count 4.
• Itraconazole pulse therapy (400 mg daily for 1 week per month, 2 pulses for fingernails, 3 for toenails) is an alternative first-line option 4.
• For superficial or distal involvement, consider topical amorolfine 5% lacquer once or twice weekly for 6-12 months, particularly in combination with systemic therapy 4.

Drug-Induced Nail Changes

• For EGFR inhibitor-induced paronychia (Grade 1), continue current dose and apply topical very potent steroids with antiseptics; use warm water or dilute white vinegar soaks (1:1 ratio for 15 minutes daily) 4.
• For Grade 2 toxicity, consider dose reduction and refer to dermatology; add oral antibiotics if secondary infection develops 4.
• Apply mid-to-high potency topical steroid ointment to nail folds twice daily for edema and inflammation 4.

Inflammatory Nail Disease

• For psoriatic nail changes affecting <3 nails, inject intralesional triamcinolone acetonide 5-10 mg/cc into the nail matrix 4.
• For nail bed involvement, apply topical steroids with or without topical vitamin D analogs 4.
• For >3 nails involved or severe disease, consider acitretin 0.2-0.4 mg/kg daily after consultation with appropriate specialists 4.

Common Pitfalls to Avoid

• Do not prescribe antifungal therapy without mycological confirmation, as many nail dystrophies mimic onychomycosis but require different treatment 4.
• Avoid aggressive interventions such as nail ablation for self-limited conditions like post-viral nail changes, which resolve spontaneously 5.
• Do not recommend vitamin supplementation beyond biotin in well-nourished patients, as there is no evidence of benefit 7.
• Recognize that topical steroids can worsen paronychia if bacterial infection is present; culture purulent material and treat infection appropriately 4.

When to Refer

• Refer to dermatology if nail changes persist beyond 6 months despite conservative management, or if >80% of the nail plate is affected with significant functional impairment 5.
• Refer to podiatry for specialized nail care in patients with complex dystrophic nails, particularly those with epidermolysis bullosa or other genetic conditions 4.
• Obtain infectious disease consultation for recurrent paronychia in immunocompromised or diabetic patients 8.