Nail Disorders and Treatments in the Aging Population

Generational Dermatology Summit New York, NY April

29, 2011

•Richard K. Scher, MD, FACP

New York, NY

Nail Changes and Aging I

• Yellow, gray, dull, opaque

• Overcurved longitudinally and transversely

• Markedly reduced growth rate

Cohen and Scher, JAAD, 1992

Nail Changes and Aging II

• Brittle, ridged, peeling, splitting: (onychorrhexis, onychoschizia)

• Lunulas may be absent

• Thickened blood vessels and elastosis of nail matrix and bed

Nail Changes and Aging III

• Up to 40% decrease in nail plate growth rate in the elderly

• A factor in 40-60% increase in onychomycosis prevalence

• Slow growth rate contributes to nail thickening (onychauxis)

Nail Changes and Aging IV

• Longitudinal ridging (onychorrhexis) corresponds to skin wrinkling

• Related to whorls of generative cells in the proximal nail matrix

• Improves with light buffing

Skin Disease in the Elderly – A Tunisian Study

• All new skin diseases in patients over age 65 examined for 1 year

• 1550 cases; mean age 72.6 years

• 16.9% due to fungal infections, the largest group, of which onychomycosis predominated

Souissi et al. Ann Dermatol Venereol 2006

Brittle Nail Syndrome (BNS)

• Normal water content = ~18%

• Higher soft; lower brittle

• Treat by re-hydrating, NH3 lactate, urea (5-20%), moisturizers, oral biotin (2.5mg daily for 3-6 months)

• Check for hypothyroidism

• Sanitizers, triclosan worsens

Water content of brittle vs normal fingernails.

1. Found ~12% water content in brittle and non-brittle nails

2. Females 2:1 to males3. BNS ↑ with age; water content ↓ with age4. More common with frequent hand washing,

exposure to chemicals, regular professional manicures

Stern et al. JAAD, 2007.

Could BNS be related to TOWL?

• TOWL (transonychial water loss) of atopic, psoriatic, and mycotic nails is much lower than that of healthy nails

Yet atopic nails are brittle! Less TOWL. Is this a contradiction? Psoriatic nails grow faster (younger). Less TOWL. Should also be less brittle! Is this also a contradiction?

• [Our TOWL study did not work]

Kronauer et al. Acta Derm Venerol, 2001.

What else may help brittle nails?

• Calcium, Zinc, Selenium, Iron, B12, Vitamin A may be helpful if there is a deficiency, but not likely otherwise

• For patients with hypocalcemia due to hypoparathyroidism, calcium improves the associated brittle nails

• Nail polish helps, French manicure; gelatin does not

What else may help brittle nails?

• Nail strengtheners with formaldehyde help, but caution: contact dermatitis and onycholysis may occur; may brittleness

• Nail polish helps, gelatin does not

• Some women taking estrogens believe nails improve; also pregnancy [anecdotal]

• Tried retinoic acid, minoxidil; did not work

• Clinical trials on new emulsion current

Faulty Biomechanics

• Bony abnormalities: abnormal gait • Nails traumatized: permanent

dystrophies, worsening of gait• Subungual hematomas may look like

melanomas (trauma, aspirin, anticoagulants)

• Pincer nails, subungual exostoses

courtesy of Wendy Roberts, M.D.

The elderly: fastest growing segment of the population

WORLDWIDE• By 2030, 71 million Americans will be

age 65 years or older; almost 20% of the population or 1 in 5 (now 12%) [10 million will be over 85 years]

• 1950: 7 workers for each retiree…2030: 3 workers for each retiree…

• The retirement support system is under pressure!

• Only 11% of the NIH budget is devoted to elderly health concerns

• Health needs of tens of millions of elderly will overwhelm hospitals and caregivers in the next 10 years

• 7-10,000 baby boomers per day are entering medicare roles

• Freudenheim. NY Times. 6/29/10.

•Genome investigators can now predict with 77% accuracy those individuals who have extended longevity to 100 years or more and are increasing

•Are you interested in this test?

Journal Science (AMA Bulletin, June 2010)

• Average American’s life expectancy is 75 years but many will live much longer

• More leisure years, more spending years • Spending rate of elderly/retirees no lower than

it was during their working years• Thus, more spending on appearance products

for SKIN, HAIR, and NAILS• Today’s elderly care about how they look; are

willing to spend more to look younger

The Good (?) News

• Sexually transmitted diseases rose 43% in American seniors during the five year period from 2005-2009 (Centers for Disease Control)

• Seniors are more ahead of that curve than non-seniors

• Hooray! Seniors are having lots of sex.

Conclusion

Alas!

Nails age along with everything else.

Summary I

• Do not abuse your nails

• They are not screwdrivers, scrapers, or staple removers

• Wear gloves for chores, gardening, etc

• Avoid trauma, chemicals, detergents

• Do not let nails grow too long – they will act like fulcrums and be injured

Summary II

• Nail cosmetics are OK: use acetone-free remover, formaldehyde- DBP-free polish

• Avoid over-aggressive nail technicians; vigorous cuticle manipulation injures the matrix and damages the nail plate

• Keep nails well moisturized and protected from excess sun exposure

• Vitamins and minerals may help

As a bright candleIn a holy place

So is the beautyOf an aging face

- Joseph Campbell

Grow old along with me

The best is yet to be

- Robert Browning