I can think of no better way to spend your postprandial hour than to talk about nail cosmetics. So, my name again is Dr. Tracey Vlahovic. I’m from Tempo. And let’s get that lecture loaded up. Dr. Shawn House says he doesn’t have to introduce me because you already know me. Alright. So, we’re going to talk about a cosmetic approach to nails and I always joke that this is my typical patient in Philadelphia. They come in wanting their nails evaluated but they come in having much nail adornment on them, so it’s a little frustrating. So, just as a disclosure I’m -- done research and I’ve been involved as a speaker for PharmaDerm, Valeant, and Innocutis. And by the way, if this could be my nails I would love that. So, let’s just start from the very beginning, a history of nail cosmetics. So, believe it or not nail polish and car paint are related. Back in the '30s, they basically had oil-based paint for cars which would take a really long time to dry. They were starting to use and starting to create lacquers for cars and basically what a man named Charles Revson did was he took lacquer and applied pigment to it. Up until then, nail polish in the '20s and '30s was transparent. So, it really had no color and you would only apply it to part of the nail. So, what Charles Revson did was he said let me take this new lacquer technology and apply pigment. And basically what happen was he created an opaque nail polish as what we know today. So, back then, again, nail polishes were not opaque. They were transparent. He created an opaque nail polish. Now, Charles Revson, that name might sound familiar because he ended up creating Revlon cosmetics. So, he took these nail polish colors that he was creating and created lipsticks on the same color and suddenly women had the choice of matching their outfit or their skin tone with an opaque nail polish. Now, some of my former students in the audience know that if I could I would look like that car all day long just covered in sequence holographic light and glitter and feathers and I would be extremely happy person. But I calm myself down to lecture. But of course, you know, this is my ideal situation. So, what is in nail polish? And you may have never really thought about this before. So, as I said it’s basic ally lacquer with pigment. But it’s much more than that. It's pigments in a volatile solvent. Think about what nail polish has to do for fingernails or toenails. It basically has to create a film on your nail plate that should last, right. It should color. It should be opaque. It should color the nail. But also it should adhere to the nail plate but also not damage it. So, there's a couple of things that in it to create what we’re looking for. Number one, are the film-formers or resins. This creates flexibility for wear. Now, the most common ingredient that is a film-former or a resin in all nail polishes and this really hasn’t changed since 1938 is nitrocellulose. Now, nitrocellulose is basically this compound that allows oxygen breathability within the nails. So you can apply the nail polish and you can still have some moisture vapor transfer which is important for nail health. So, that’s one thing. Nitrocellulose is pretty much and still all in nail polish. But there’s something called toluene sulfonamide that is still in some nail polishes. But unfortunately, toluene is an extreme allergen. And people who develop allergies to nail polishes are often allergic to toluene. So, if you see a nail polish brand that is hypoallergenic it will not have toluene in it. Now, plasticizers are also a component of nail polish. Now, what does that do? It allows it to be freely mobile in the bottle. Think about nail polish, if it was hard as a rock, you’d never be able to use it. So, pliability in the bottle is obtained with the phthalates or DBP as well as camphor. Now, the problem is is DPB is also an extreme allergen. So, people who again, who’d developed allergies you have to give them either 3-free or what’s called 5-free nail polish which is DBP free as well as toluene, formaldehyde resin, and camphor free. So, those nail polishes don‘t have the long-lastingness that polishes that do have DBP in it. But its one of those things where people go for that.

[05:01] Tracey Vlahovic: You just probably have to change it more often. You also have solvents because, remember, it has to be involve with solvent acetate, ketones, xylene, and alcohols as well as your pigmentation. But my personal favorite of what’s in nail polish are the specialty filters. Again, nail polishes are opaque. But we tend to have all these different finishes now whether it's glitter or, again, holographic, you know, colors and things like that. So, one of the things that they have found is if you look at that fish, that's obviously a real fish. When you catch a fish typically their scales have some holographics sort of coloration to them. They actually grind fish scale down and use the guanine that’s in there that what’s causing that coloration and user that in nail polish. So, you’re wearing ground up fish scale [Laugh] as well as mica flakes and there’s also bismuth. So, there’s all different types of filters that they can use to create the effect that you want. So, with nail polish, home nail polish application would be considered a base coat or something that would allow the color to adhere to the nail plate. Two coats of colors again enamel or varnish and then a clear top coat to create sort of seal in the nail color so that it lasts. Now, nail polish in general is relatively safe and can be used in pregnant patients as well as we have even nail polishes for children. But as I mentioned before we have issues with both toluene and DBP or the phthalates that can create a contact dermatitis. So, as you can in the picture on the top those are patients who’ve had contact dermatitis, issues with some of the products or some of the components in nail polish. Now, the other thing that you can actually develop contact dermatitis, too, if you’re allergic to nickel. If you ever take a nail polish bottle and shake it up you’ll hear like a little bead. Well, once upon a time, they only used to use metal beads that were nickel based. So, if you have a nickel allergy you could conceivably have an issue with nail polish. Now, they’ve changed that to plastic bead in most cases. The other thing that we will see is that with reds and purple nail polishes there will be nail plates staining. So, the bottom picture is a picture of the yellow discoloration that can happen after using red or purple nail polish. Now, that can last up to 14 days and you could simply take a blade and scrape that off. However, patients will come in again thinking that they have onychomycosis and in reality it’s just superficial staining on the nail plate. I have an interesting case back in Philly where I had a young boy, I call him a punk. If you’ve been to Philly you know when I say punk you know what I’m talking about. This punk 18-year old kid came in with his mother and he wouldn’t talk to me. He just gave me like the grunts, you know, like hmm-mm, mmm-mm, no. And he had green stained nails, all 10 nails were stained green. And so, I said to him I said do you have socks that are green, do you have the inside of your shoes that are green. He’s like no, no. And I said okay, well, I’m just going to go get a Dremel and I’m going Dremel this off because I guarantee you this is superficial staining. So, as I walked into the room with the Dremel his mother said, oh, I remember exactly what happened. I gave him green socks for Christmas and he basically never took them off. And I'm like not only is this kid a punk, he’s a dirty punk. But it just goes to show that not only just nail polish can stain your nails but the environment can stain your nails. So you have to be aware of that. Again, it’s a superficial staining. You can just Dremel it off. Now, acetone remover certainly we as healthcare workers have to be very aware of using nail polish and nail polish products around patients. So, just the process of removing nail polish can be irritating. Some of the products are a little bit gentler, but true acetone based extremely drying and certainly that can create a lot of havoc for the skin. So nail polish is actually the most popular nail cosmetic in the world and it allows patients to have self-expression. So, the patient who has the Skittle colored nails, that’s one of my patients who have sickle-cell anemia, I always say she tasted rainbow. She would just delight with glee when she would come and then show me her nails, the bottom picture with the plate, it’s another patient of mine and then the other two, well, I wish they were my patients. One has the Hello Kitty manicure and then the other one is just fabulous, pretty much a very limited in your shoe gear as to what you can wear with that type of pedicure. But that said, I basically believe that if you Google nail polish or nail art, I mean, it's one of the most Googleable things that are out there. There is so much self-expression that you can see on Instagram, in Facebook and YouTube, so it’s making people into sort of instant star. So, it certainly something that we as practitioners have to be aware of.

[10:01] Tracey Vlahovic: It's what to deal with it. And one of the things is is when we do a nail culture or nail biopsy. One of my good friends who's a dermatopathologist Dr. Adam Rubin and his group in Philadelphia took a look at nail polish and the histology of nail polish. They were getting specimens upon specimens both again for nail biopsies and for cultures. Seeing this of discoloration on the surface of the nail and said, okay, well, alright let's take a look at this a little closer. So they found three different patters that nail polish can have on the surface of the nail plate. One of them actually is polarizable. But the problem is is that this can be to someone who doesn't know this article or doesn't look it at that way. It can be misconstrued as having as a hematoma or even as melanoma. So it's one of those things that before you either examine a patient who's coming in for a nail issue or you're going to do any kind of nail procedure remove the nail polish. I know that sounds logical, but you will assist the dermatopathologist by removing the nail polish. Because again not all of them will be aware of what it looks like histologically. So just bottom line, just remove it and do it really well because remember it's going to get in those crevices before you send something to the lab. So let's talk about other types of nail art besides nail polish. Well, one of the most popular for a long time is acrylic nails. Now what are acrylic nails? They're either actual whole nails or extensions on your regular nail that is basically a pre-formed piece of plastic. And it's usually glued on and it's sculpted to the pattern that you want. You can see that there's something called a squoval. Who knew? Square, oval or squoval-shaped nails. Now the problem is that for years with acrylic nails they have gotten a bad wrap and there's a lot of good reason for it. Number one, acrylic nails as your regular nail grows out it lifts up and you can get a space there that microorganisms can just have a field day. The other thing is is that it can harbor the bacteria fungus and there's been cases both in pediatric ICUs as well as ICUs of nurses bringing communicable diseases through their nails. So what the World Health Organizations as well as the CDC published and said that acrylic nails basically should be banned in the hospital. But it goes further than that. Of course acrylic nails that make sense, but what about nail polish? Well, what they did was they did a study that said, okay, let's have people with no nail polish, let's have people with fresh nail polish and people with a week-old manicure and see what happens. See how much bacteria is harbored on that nail polish. And so what they found was that even folks who had any kind of nail polish on, the bacteria count was higher than those who didn't have nail polish. And that was after a surgical scrub. The problem is is that all of these different studies that are out there both with acrylics and even just scrubbing with nail polish are really inconclusive because it's hard to do a clinical trial based around that. So the studies are a bit inconclusive. Certainly my take away from all of these is obviously don't wear acrylic nails at the hospital. Probably is banned at your hospitals. And if you're going to wear nail polish you should change it weekly. And if you have any chips or cracks in the nail polish remove it. Or just leave all the nail art to your toe nails which are covered at the hospital and leave your finger nails bare. What about gel nails? Well gel nails have certainly taken a huge leak forward over acrylic nails. And why do gel nails exist? Well, gel nails exist because they're long-wear and they're usually chip and crack resistant. Now, what are they? Basically it's a monomer and a photo initiator. So you have usually two monomers and a photo initiator and then it's applied. Then you apply either UVA or some sort of ultraviolet lamp to it and it hardens. So the thing is, is it long last anywhere from two to four weeks depending on what you're doing. So the problem is with these gel nails is that you have to remove them with an acetone soak. So number one, that's not good for your skin. Number two, the process of it because then you peel away any gel nail resin that's left over can actually cause thinness and brittleness to the nails. And they actually did confocal microscopy testing of the nail plate that had gel nails and found that these patients definitely had more brittleness and thinning than those who do not have gel nails. So that's something. Gel nails do have that issue. But also the big story right now is the ultraviolet light exposure that you have.

[14:58] Tracey Vlahovic: If you think about it, you have both hands down and maybe the feet. So it's about 10 minutes of ultraviolet exposure about once a month or twice a month, we'll say. What they have found was that it basically equates to spending an extra three minutes in the sun. The people we have to really worry about to have this ultraviolet light exposure at least twice a month would be those who are on something that a photosensitizing medication like doxycycline or one of the Retin-As. So those are the patients that perhaps they should wear gloves with the fingernails cut out. So they have minimal exposure or where they can wear SPF, sun screen, or just avoid it all together. So there's a lot of controversy out about that right now. But it seems to right now be at the level where it just adds about three minutes if you were in the sun to your lifetime each month. So the other thing that’s kind of interesting about gel nails is -- okay, well this morning I talked a little bit about Jublia, and there's another medication called keratin. Now, the problem is is that patients aren't very good about using things on a daily basis. So what if we can harness those who like to use these products like gel nails that are going to last for two to four weeks and made them basically medication little vehicles. So one study recently took gel nails and applied either terbinafine or amorolfine. Now amorolfine is not available in the United States. It's only available in Europe as an antifungal. It's not a very good antifungal. But it's over the counter and it's easy to get. And basically what they found was they created a very specific resins for nails that could be applied and then apply these medications. They found that amorolfine was able to get through to the nail plate very well, terbinafine wasn't. They thought terbinafine kind of got stuck during the whole polymerization process with the UV light. And maybe the pores within the gel nail itself wouldn't allow the terbinafine to get through to the nail plate. So certainly it has potential, but we're not there yet. We're still in the scientific bench study phase. But certainly it could be interesting to take, say, the two medications that just came out in the market and see if they could be applied to gel nails and where that could take. So again just to insure patient compliance. Now, I do love this picture. Dr. Spalding is podiatrist in Tennessee and he wrote this book called "Death by a Pedicure". I always feel like it should be followed by a dun, dun, dun, dun, right, because it's just like very evil looking type of picture. But the reality is is that you know the CDC looks at the instrumentation that is used in pedicures as critical instruments, meaning that they are being exposed to both skin and vascular structures. So as I mentioned before you have nail fungus and then the person after you doesn’t in theory because they are not properly sterilizing these instruments it could be passed on from patient to patient to patient. And not just fungus, we're talking about viruses, bacterial infections, certainly hepatitis and all of those things who have potential as well. In reality cold sterilization has to be either eight or ten hours. Salons aren't going to do that. Salons aren't also going to pay for to have autoclave instruments. So we're dealing with that, number one. Number two, oftentimes there's scraping at the hyponychium. So they're breaching that border. They're pushing back the cuticle which is also breaching the border as well. If you damage those two portals, eventually that should be sealed you are going to run into problems and these are just some of the patients that I've had experienced issues with pedicures. The patient on the bottom with the second toe, the issue that she had was that the salon that she went to changes their workers every six weeks. So when she went back to complain it basically she had to go to an infectious disease doctor, get an IV. She almost lost her toe. They basically said, sorry, all those folks are gone. In reality from state to state there's different regulations. And there's not enough people at the sate level to go salons and police them with these regulations. So you really are taking your life into your own hands as -- no pun intended --when you go and use the instruments that they already there. So my suggestions to my patients is, number one, bring your own instruments. Number two, do not have them scrape under the hyponychium or scrape at the cuticle. Just have them file paint and polish. Now the other thing that you have to worry about with pedicures is the chairs that have the water piped in. That's actually where the "Death by Pedicures" happened. There's been two, I think possibly three at this point reported.

[19:55] Tracey Vlahovic" Those filters don't get changed. So pseudomonas and other bacteria can kind of hang out in those filters and they might just dump some Clorox on that water, but it's not enough if you don't change that filter. So what happen was as the patients who went in or clients I should say who had pedicures had shaved there legs previous to have these pores entry that were there pseudomonas got in, other bacteria got in. They had a raging infection and then actually the one patient end up losing her leg and then dying. So it's one of those things where pipeless chairs are a good thing. Or a place that only has a basin with a lighter. So what can do as practitioners? Well, in theory, if you can't beat them join them. We can have medical spas where we have own practitioners that we hire to do these procedures as well as healthy, safe pedicures, meaning using autoclave instruments. If there's an issue, if they're diabetic, if they have any sort of vascular issues there's a podiatrist on call. There's a podiatrist right next door, right part of that practice. So certainly you can create that business for your self and do things the right way so that patients who want to employ this service can have a better situation ultimately. So what about onychomycosis in nail polish? Well, many of my patients will come in and use nail polish to camouflage their nail disease or they use Band-Aids. Band-Aids get expensive after a while for some of my patients. Some nail polish seems like a good alternative. However, what about using it with other treatments? Well, up into the two recent medications came out we really couldn't. Ciclopirox, lacquer you cannot use with nail polish. You can't have a lacquer and a lacquer together. And certainly pedicures could exacerbate or even re-infect these patients who are on therapy. Now just so you know nail polish can come in ease with nail polish with both tavaborole, ethniconazole were not done in phase three clinical trials. So patients had to be pedicured, nail polish free during those clinical trials. So basically what has happened is, okay, we have these two products that are alcohol-based solutions, what can happen if we actually expose them to nail polish? So the next two studies I'm going to talk about were done in vitro, okay. These are in vitro cadaver finger nails that are not diseased. So basically what was done and this paper just came out. I'm the author on it. There were two. We did two studies, but the study that I want to talk to you about specifically is using multiple coats of nail polish which is more consistent with what patients do on a daily basis. So cadaver finger nails from several female donors, again they were none diseased. Group one had four coats of nail polish a base coat, two coats of color and a clear coat. Group two had one brand of salon brand nail polish and if you are somewhat savvy with nail polish, you know that there's a little bit of a difference between salon nail polish and the stuff that you can buy at the drug store. That's with the home brand nail polish is. And then group four was one coat of home brand nail polish and group five was untreated control. All groups had tavaborole applied to them everyday for 14 days. And on day 15 data was collected. Now the one graph it says through one layer of nail polish that's basically showing that it actually can penetrate through nail polish. The one that says through multiple layers of nail polish shows that it's able to penetrate through four coats of nail polish. So again this is in vitro data. This is not a human in vivo with onychomycosis. Certainly that is going to happen. We are going to see what the data is. What the efficacy is with humans who have onychomycosis using nail polish. But at this point, this is really lovely data to see the in vitro cadaver finger nails seeing that it has the ability to penetrate through four coats of nail polish. Now what about ethniconazole 10% solution in nail polish? Well, their study was done a little bit differently. Basically the cadaver finger nails had either some kind of red nail polish. So two coats of Dior, Essie and Revlon and gain those of us who were nail polish savvy in the audience know that there's a difference between Dior, Essie and Revlon, that there's a slight difference. And then one group of the untreated control. The nails had ethniconazole applied daily for almost 7 days. They had two days off during the week end and on day eight data was collected. So basically what this shows is that two coats of nail polish did not appear to inhibit permeation of ethniconazole through the nail. So that's all it's saying is that there was no difference in permeation between the nails that had nothing applied to the no nail polish and those that have two coats of nail polish. So again, this is all in vitro data. You can take from this and extrapolate this from how you wish, but certainly in my own practice I know how I've been handling this data with my patients.

[24:55] Tracey Vlahovic: Now, what about if you have a patient who has bridging nail dystrophy that could be related to onychomycosis or psoriasis or something? We can use a product called poly-ureaurethane 16% nail solutions. It's commonly known as Nuvail. This was FDA approved specifically for nail dystrophy. Now this is sticky. This is not a lacquer, but it's just basically a film that can get very sticky. So I like to use this in patients who have a hammer toe with their nail that's been just really biomechanical sort of tested. Patients again who have both loins, angiorrhexis, post nail procedures things like that. And interestingly enough when they did the clinical trials for poly-ureaurethane they actually looked it for onychomycosis even though it's specifically approved for onychomycosis that's what they studied. And so basically the subjects that were in the trial for poly-ureaurethane had poly-ureaurethane applied once daily for 6 months. And as you can see the progression of pictures, the first picture is base line, then it's three months then six months. The end of six moths you still see that there's some nail fungus left, but actually those subjects were KOH and culture negative. And so what they said was, okay, well, let's give you a 6 month break, you use nothing, right. You're not going to use any product at whatsoever. So they brought those subjects back at 12 moths again 6 months of not using anything. And as you can see the nail continued to progress in a positive direction. So what poly-ureaurethane is doing to nail fungus? We're not exactly sure. But certainly it could be interesting to see how this product which basically acts likes a sealant. If you seal your backyard porch where your wooden areas and your backyard you have to put a sealing on to protect it from the weather. So that's kind of how this is acting. It's creating this very flexible, breathable film for the nail. So certainly this could be in theory use concomitantly with again to the two new antifungals. And that's actually going to be a study that's going to be done very, very soon, is to see, do they work in harmony together. Now what about cosmesis that we can perform as podiatric physicians? Well, there's something called Cariflex which is a cosmetic resin. The company that created this product they also make teeth lacquers and things like that. So I would say they go from teeth to toes. Somehow they made that connection. It's an organic resin that you have to use ultraviolet light. It is not a gel nail because it is not removed with acetone. And basically it creates this really water type seal that's cosmetically appealing to patients. So as you can see you have a patient here who is just very micronesia dystrophic nail and you can create a really nice looking nail for that patient. But the thing is is I like to think of this as a protection. It's like a good barrier for trauma. So for instance you could use on ballerinas which it would help reduce some of the trauma they're getting in there point shoes. Hockey players, things like that. But it's a very simple process to do. You deprive the nail. You apply a bond which is not odorous. You apply the resin. You use UV light for two minutes. You shape and file and they're good to go. They can use nail polish on top of it. They can remove nail polish they just cannot deprive the nail. They can only file it. The other thing with Cariflex is that it can last up to 6 to 9 weeks or even 12 weeks depending on that patient's nail growth. So you can use this to camouflage a host of problems not just on onychomycosis, but certainly someone who's had multiple nail procedures in the part, psoriasis, you know, lichen planus, things like that. And that's it for me. Thank you so much for your attention. Are there any questions?