Is onycholysis more likely caused by acetone irritation or an acrylate glue allergy?

Onycholysis: Acrylate Allergy vs. Acetone Irritation

Acrylate glue allergy is more likely to cause nail separation (onycholysis) than acetone irritation, particularly when accompanied by dystrophy, paronychia, and eczematous changes. 1, 2

Key Distinguishing Features

Acrylate Allergy Presentation

• Allergic contact dermatitis from acrylates causes onycholysis along with dystrophy and paronychia, creating a characteristic triad that distinguishes it from simple irritant reactions 1
• The clinical pattern includes psoriasiform changes with subungual hyperkeratosis, which can be severe enough to mimic nail psoriasis 2
• Patients report intense itching and worsening when reusing acrylic products, with improvement during periods of avoidance—a classic allergic pattern 1
• The reaction is confined to fingers where acrylic materials were applied, providing clear spatial correlation 1

Acetone Irritation Presentation

• Acetone primarily causes irritant contact dermatitis of the periungual skin rather than true allergic reactions 3
• The American Academy of Dermatology notes that irritant-induced onycholysis requires the nail plate to become detached first, after which the separated portion becomes opaque and loses transparency 3
• Irritant onycholysis lacks the dystrophic changes and severe paronychia characteristic of acrylate allergy 3

Diagnostic Approach

Clinical History Red Flags for Acrylate Allergy

• Use of artificial nails, gel polish, or nail strengthening products in beauticians, nail technicians, or musicians (particularly guitarists) 1, 4
• Temporal relationship with product use: symptoms worsen with reapplication and improve with cessation 1
• Involvement of multiple nails where products were applied, rather than isolated trauma 2

Physical Examination Findings

• Acrylate allergy: Look for eczematous changes, severe dystrophy, paronychia, and psoriasiform features including marked subungual hyperkeratosis 1, 2
• Acetone irritation: Look for inflamed nail folds, simple separation without severe dystrophy, and irritant dermatitis of surrounding skin 3

Confirmatory Testing

• Patch testing is essential for definitive diagnosis of acrylate allergy 4, 2
• The most common sensitizing acrylates are 2-hydroxyethyl methacrylate (2-HEMA), 2-hydroxyethyl acrylate (2-HEA), ethyleneglycol-dimethacrylate (EGDMA), and 2-hydroxypropyl methacrylate (2-HPMA) 1, 4
• 2-HEMA detected 100% of sensitized patients in one study, making it an excellent screening allergen 4

Critical Clinical Pitfall

• Acrylate-induced onycholysis with psoriasiform changes is frequently misdiagnosed as nail psoriasis and treated unsuccessfully with psoriasis therapies 2
• Always elicit a history of acrylic manicure use in patients with suspected nail psoriasis that is refractory to treatment 2

Management Implications

For Confirmed Acrylate Allergy

• Complete avoidance of all acrylate-containing products is mandatory 1, 2
• Trim the separated nail plate back to the point of firm attachment to prevent debris accumulation 3
• Apply high-potency topical corticosteroid ointment twice daily to inflamed nail folds 3

For Acetone Irritation

• Discontinue acetone exposure and switch to acetone-free nail polish removers 3
• Trim separated nail and apply topical emollients daily to periungual folds, matrix, and nail plate 3
• Avoid prolonged water exposure and harsh chemicals during healing 3

Common to Both

• Monitor for secondary infection, which occurs in up to 25% of onycholysis cases 3
• Keep the nail bed dry, as moisture promotes colonization by environmental flora including Candida and Pseudomonas 5