Approach Considerations
It is important to exclude the possibility of damage to the nail matrix from long-term arsenic exposure, disorders of the microcirculation (ie, arteriosclerosis, Raynaud disease), and disorders of oxygenation (ie, anemia, polycythemia vera, sarcoidosis). [1] It is also vital to rule out systemic diseases, exogenous insults, and primary inflammatory dermatologic conditions impacting the nail matrix. [1]
Treatment of Brittle Nail Syndrome
Biotin
Biotin is a water-soluble B vitamin commonly found in egg yolk, cereal, peanuts, walnuts, and milk and may be used to treat symptoms of brittle nail syndrome. [24] The majority of studies investigating the impact of biotin on brittle nails have been small and patients were successfully treated with a dose of 2.5 mg/day. [25, 26, 27] Doses ranging from 2.5-10 mg/day have been suggested to be effective. Additional studies with larger sample sizes are needed to elucidate the magnitude of its efficacy. Of importance, oral biotin supplementation has been implicated in interference with blood testing, including tests measuring levels of troponin, thyroid function, and prolactin. [28] It may also impact pregnancy testing. [29] Therefore, it is important that patients disclose to their healthcare providers whether they are on biotin supplementation in order to ensure the most optimal clinical care. Patients taking typical-dose biotin supplements should withhold their dose at least 8 hours prior to any laboratory tests.
Hydroxypropyl chitosan
In patients with brittle nail syndrome, hydroxypropyl chitosan–based nail lacquer has been associated with a clinically relevant improvement of nail appearance. In one study, the use of oral biotin in addition to the nail lacquer prompted a synergistic effect associated with even further clinical improvement. [30, 31]
Poly-ureaurethane
Poly-ureaurethane is a polymeric hydrophobic solution that can be applied to the nail plate, which coats it and traps in moisture. Indicated for nail dystrophy, nail splitting, and fragility, it has also been suggested to improve the clinical appearance of nails affected by onychorrhexis. [7, 32]
Commercially available nail hardeners
Over-the-counter nail hardeners can be beneficial for strengthening nails but may also paradoxically contribute to worsening brittleness. [33] The formaldehyde in nail hardeners is considered the damaging agent in the paradoxical worsening, and it has also been linked to risk of allergic contact dermatitis and onycholysis in patients. [34, 35]
Nail moisturizers
Nail moisturizers in combination with lukewarm water soaks lasting 10-20 minutes can increase hydration in the nail plate and improve the appearance of nail fragility. Examples of nail moisturizers are petroleum jelly, lactic acid lotion, mineral oil, and urea cream. [2] In severe cases, patients may consider using these moisturizers under occlusion covered by cotton gloves. [2, 36]
Prevention
To prevent brittle nails, it is helpful to follow a diet that is well-balanced in vitamins and minerals that are beneficial for the nails and skin. Direct trauma to the nails should be avoided. Patients should be advised to wear cotton gloves whenever involved in intensive manual work. It is recommended that patients take caution with the overuse of nail polish remover, as it can be drying to the nails. Other options for prevention include keeping nails short to reduce the surface area accessible for weakening and avoiding vigorous or frequent manicures and long-term, repetitive use of artificial nails.
Long-Term Monitoring
Nail disorders can be difficult to treat and require time to see promising results. Successful resolution of brittle nails may even require multiple treatment strategies. [7] It is important that healthcare providers and patients collaborate to establish an optimal management plan.
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Brittle nail syndrome: Significant longitudinal ridging of the L1 and R1 fingernails in an otherwise healthy 77-year-old woman, consistent with onychorrhexis stage 3 ridging per grading criteria proposed by van de Kerkhof and colleagues. Courtesy of Amanda E Zubek, MD, PhD, FAAD.
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Brittle nail syndrome: Horizontal splitting of the free margin of the nail consistent with lamellar onychoschizia. Courtesy of Springer Healthcare (Dermatology and Therapy, 20 Nov 2019).
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Brittle nail syndrome: Moderate-to-significant longitudinal ridging of the R2-R5 fingernails in an otherwise healthy 77-year-old woman. Courtesy of Amanda E Zubek, MD, PhD, FAAD.
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Brittle nail syndrome: A 75-year-old woman with a history of hypothyroidism with moderate-to-severe longitudinal ridging of the L2-L4 fingernails consistent with onychorrhexis. Courtesy of Amanda E Zubek, MD, PhD, FAAD.
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Brittle nail syndrome: A 75-year-old woman with a history of hypothyroidism with moderate-to-severe longitudinal ridging of the R2-R4 fingernails, consistent with onychorrhexis. Courtesy of Amanda E Zubek, MD, PhD, FAAD.
Tables
Lamellar splitting defined as onychoschizia |
0 = None, clear of clinical signs of lamellar nail splitting |
1 = Mild, distal furrows, parallel to the back surface, not involving the entire free edge of the nail plate |
2 = Moderate, distal parallel furrows of the superficial nail plate involving the complete free edge of the nail plate |
3 = Severe, distal lamellar splitting of the complete free edge of the nail plate, lamellar splits covering at least one third of the nail plate |
Horizontal nail splitting from the free edge of the nail plate |
0 = None, clear of clinical signs from the free edge of the nail plate |
1 = Mild, one superficial horizontal split of the distal nail plate |
2 = Moderate, 2-3 horizontal splits of the distal nail plate |
3 = Severe, multiple horizontal splits leading to loosening of at least one third of the distal nail plate |
Assessment of ridges and longitudinal grooves |
0 = None, clear of any signs of ridging and longitudinal grooves |
1 = Mild, few plane ridges and longitudinal grooves |
2 = Moderate, few deep ridges and longitudinal grooves |
3 = Severe, more than 70% of the nail plate showing deep ridges and corresponding grooves |
Longitudinal splitting as derived from the nail matrix and defined as onychorrhexis |
0 = None, clear of clinical signs of longitudinal nail splitting |
1 = Mild, one single, superficial longitudinal split of the nail plate |
2 = Moderate, at least one deep longitudinal split of the entire nail plate |
3 = Severe, multiple, superficial and deep longitudinal splits of the nail plate |
