Shari R. Lipner, MD, PhD

To the Editor:

Patients with skin, hair, or nail concerns often utilize online resources to self-diagnose or learn more about physician-diagnosed conditions. The American Academy of Dermatology (AAD) website offers the public access to informational pages categorized by disease or treatment (https://www.aad.org/public). We sought to evaluate the nail content by searching the Patients and Public section of the AAD website to qualitatively and quantitatively describe mentions of nail conditions. Psoriasis, psoriatic arthritis, atopic dermatitis, and ringworm content also were analyzed and compared to nail content. The analysis was performed on September 7, 2019.

Of the 73 topics listed in the Diseases and Treatments section of the site, 17 (23%) specifically mentioned nail symptoms or pathology (Table). Three additional topics—atopic dermatitis, cellulitis, and neurodermatitis—recommended keeping nails short to prevent injury from scratching. There was 1 mention of obtaining fungal cultures, 2 of nail scraping microscopy, 2 of nail clippings, and 2 of nail-related cancers. There were no mentions of nail biopsies. The total number of unique clinical images across all sections was 300, with 12 of nails. The video library contained 84 videos, of which 6 focused on nail health.

Many of the included images were not representative of common clinical findings. The nail lichen planus image showed pitting instead of more typical findings of nail plate atrophy and pterygium. The nail melanoma image showed thickened yellow toenails and the fifth toenail with a thin gray-brown band instead of an isolated wide black band. The nail fungus section included images of superficial onychomycosis and severe onychodystrophy instead of showing more common changes such as distal onycholysis with subungual hyperkeratosis, which is typical of the most common subtype, distal lateral subungual onychomycosis.⁵ Onychomycosis was referenced again in the ringworm section with 1 image repeated from the nail fungus section and another image that appeared to be a subungual hematoma.

The AAD website offers important patient education resources; however, nail content is underrepresented on this platform. Dermatologists are experts on nail disease, and increased efforts are needed to educate the public about frequently encountered nail signs and symptoms that could signify a serious underlying condition.

After our original search and analysis, new nail topics, images, and videos have been added; therefore, there has been a positive trend toward new nail content being added to site, which will greatly benefit patients.

To the Editor:

Patients with skin, hair, or nail concerns often utilize online resources to self-diagnose or learn more about physician-diagnosed conditions. The American Academy of Dermatology (AAD) website offers the public access to informational pages categorized by disease or treatment (https://www.aad.org/public). We sought to evaluate the nail content by searching the Patients and Public section of the AAD website to qualitatively and quantitatively describe mentions of nail conditions. Psoriasis, psoriatic arthritis, atopic dermatitis, and ringworm content also were analyzed and compared to nail content. The analysis was performed on September 7, 2019.

Of the 73 topics listed in the Diseases and Treatments section of the site, 17 (23%) specifically mentioned nail symptoms or pathology (Table). Three additional topics—atopic dermatitis, cellulitis, and neurodermatitis—recommended keeping nails short to prevent injury from scratching. There was 1 mention of obtaining fungal cultures, 2 of nail scraping microscopy, 2 of nail clippings, and 2 of nail-related cancers. There were no mentions of nail biopsies. The total number of unique clinical images across all sections was 300, with 12 of nails. The video library contained 84 videos, of which 6 focused on nail health.

Many of the included images were not representative of common clinical findings. The nail lichen planus image showed pitting instead of more typical findings of nail plate atrophy and pterygium. The nail melanoma image showed thickened yellow toenails and the fifth toenail with a thin gray-brown band instead of an isolated wide black band. The nail fungus section included images of superficial onychomycosis and severe onychodystrophy instead of showing more common changes such as distal onycholysis with subungual hyperkeratosis, which is typical of the most common subtype, distal lateral subungual onychomycosis.⁵ Onychomycosis was referenced again in the ringworm section with 1 image repeated from the nail fungus section and another image that appeared to be a subungual hematoma.

The AAD website offers important patient education resources; however, nail content is underrepresented on this platform. Dermatologists are experts on nail disease, and increased efforts are needed to educate the public about frequently encountered nail signs and symptoms that could signify a serious underlying condition.

After our original search and analysis, new nail topics, images, and videos have been added; therefore, there has been a positive trend toward new nail content being added to site, which will greatly benefit patients.

To the Editor:

Patients with skin, hair, or nail concerns often utilize online resources to self-diagnose or learn more about physician-diagnosed conditions. The American Academy of Dermatology (AAD) website offers the public access to informational pages categorized by disease or treatment (https://www.aad.org/public). We sought to evaluate the nail content by searching the Patients and Public section of the AAD website to qualitatively and quantitatively describe mentions of nail conditions. Psoriasis, psoriatic arthritis, atopic dermatitis, and ringworm content also were analyzed and compared to nail content. The analysis was performed on September 7, 2019.

Of the 73 topics listed in the Diseases and Treatments section of the site, 17 (23%) specifically mentioned nail symptoms or pathology (Table). Three additional topics—atopic dermatitis, cellulitis, and neurodermatitis—recommended keeping nails short to prevent injury from scratching. There was 1 mention of obtaining fungal cultures, 2 of nail scraping microscopy, 2 of nail clippings, and 2 of nail-related cancers. There were no mentions of nail biopsies. The total number of unique clinical images across all sections was 300, with 12 of nails. The video library contained 84 videos, of which 6 focused on nail health.

Many of the included images were not representative of common clinical findings. The nail lichen planus image showed pitting instead of more typical findings of nail plate atrophy and pterygium. The nail melanoma image showed thickened yellow toenails and the fifth toenail with a thin gray-brown band instead of an isolated wide black band. The nail fungus section included images of superficial onychomycosis and severe onychodystrophy instead of showing more common changes such as distal onycholysis with subungual hyperkeratosis, which is typical of the most common subtype, distal lateral subungual onychomycosis.⁵ Onychomycosis was referenced again in the ringworm section with 1 image repeated from the nail fungus section and another image that appeared to be a subungual hematoma.

The AAD website offers important patient education resources; however, nail content is underrepresented on this platform. Dermatologists are experts on nail disease, and increased efforts are needed to educate the public about frequently encountered nail signs and symptoms that could signify a serious underlying condition.

After our original search and analysis, new nail topics, images, and videos have been added; therefore, there has been a positive trend toward new nail content being added to site, which will greatly benefit patients.

Residency application is an arduous experience for many medical students. The National Resident Matching Program reported that US medical school seniors who matched into dermatology applied to a median of 90 programs and attended 9 interviews in 2019.¹ High application and interview travel costs are a disadvantage for applicants from lower socioeconomic backgrounds. We propose that the coronavirus disease 2019 (COVID-19) pandemic should serve as a call to action for dermatology to update and promote a more equitable, time-effective, and cost-efficient residency interview process.

In light of COVID-19, dermatology residency program directors have recommended a holistic application review process, taking into consideration “disparities in strength of applications due to lack of opportunity for students with smaller home programs or in areas more affected by this crisis.”² However, in a 2018 survey of 180 dermatology faculty members, 80% stated that time spent reviewing residency applications was already excessive.³ The Association of American Medical Colleges reported that for medical student applicants with US Medical Licensing Examination Step 1 scores lower than 237 or higher than 251, the value added by submitting one additional application beyond means of 43 (95% confidence interval [CI], 34-53) and 34 (95% CI, 28-41), respectively, is reduced relative to the value added by each application before reaching the point of diminishing returns.⁴ Therefore, we suggest limiting the number of applications per applicant to the upper bounds of the CI for the lower US Medical Licensing Examination Step 1 score (53), facilitating a more detailed review of fewer applications by each program and limiting student expenses.

On May 7, 2020, the Association of American Medical Colleges made a statement strongly encouraging medical school and teaching hospital faculty to conduct interviews through videoconferencing.⁵ Videoconferencing interviews (VCIs) minimize travel-associated health risks, providing a more equitable structure for applicants and programs in areas disproportionately impacted by the pandemic. In the 2018 survey of dermatology faculty members, only 11% believed that applicants interviewing virtually received equal consideration to those interviewing in person; a solution to this problem would be to mandate that all applicants use VCIs during the COVID-19 pandemic.³ This coming year, residency programs may elect to replace in-person interviews with VCIs, or they may utilize VCIs as screening tools to narrow down the applicant pool and for students to rank their preferred programs prior to an in-person interview. By inviting fewer applicants for in-person interviews, travel-associated health risks, financial costs, and missed educational activities would be minimized. Given that many medical students have had academic activities cancelled or postponed due to COVID-19, student opportunities for live clinical experiences should be maximized.

As programs plan for future application cycles beyond COVID-19, they must work to balance competing interests. Videoconferencing interviews allow for improved access to interviewing for applicants of lower socioeconomic classes, improved geographic mobility of applicants, and increased flexibility in accommodating faculty schedules with reduced time away from patient care and research; however, with VCIs one may lose the personal element that comes from the in-person interview, including interactions among applicants, faculty, current residents, and staff on the day of interview, as well as the departmental tour. Additionally, the quality of VCIs may be diminished by technical difficulties and the possibility of distractions, making standardization of the interview experience for applicants challenging.

The COVID-19 pandemic will surely leave its mark on the residency application cycle. We must take time now to collaborate and brainstorm creative solutions to maximize the equity and efficiency of the application process for both residency programs and students. We welcome reader feedback on these ideas and other possible solutions in the form of Letters to the Editor.

Residency application is an arduous experience for many medical students. The National Resident Matching Program reported that US medical school seniors who matched into dermatology applied to a median of 90 programs and attended 9 interviews in 2019.¹ High application and interview travel costs are a disadvantage for applicants from lower socioeconomic backgrounds. We propose that the coronavirus disease 2019 (COVID-19) pandemic should serve as a call to action for dermatology to update and promote a more equitable, time-effective, and cost-efficient residency interview process.

In light of COVID-19, dermatology residency program directors have recommended a holistic application review process, taking into consideration “disparities in strength of applications due to lack of opportunity for students with smaller home programs or in areas more affected by this crisis.”² However, in a 2018 survey of 180 dermatology faculty members, 80% stated that time spent reviewing residency applications was already excessive.³ The Association of American Medical Colleges reported that for medical student applicants with US Medical Licensing Examination Step 1 scores lower than 237 or higher than 251, the value added by submitting one additional application beyond means of 43 (95% confidence interval [CI], 34-53) and 34 (95% CI, 28-41), respectively, is reduced relative to the value added by each application before reaching the point of diminishing returns.⁴ Therefore, we suggest limiting the number of applications per applicant to the upper bounds of the CI for the lower US Medical Licensing Examination Step 1 score (53), facilitating a more detailed review of fewer applications by each program and limiting student expenses.

On May 7, 2020, the Association of American Medical Colleges made a statement strongly encouraging medical school and teaching hospital faculty to conduct interviews through videoconferencing.⁵ Videoconferencing interviews (VCIs) minimize travel-associated health risks, providing a more equitable structure for applicants and programs in areas disproportionately impacted by the pandemic. In the 2018 survey of dermatology faculty members, only 11% believed that applicants interviewing virtually received equal consideration to those interviewing in person; a solution to this problem would be to mandate that all applicants use VCIs during the COVID-19 pandemic.³ This coming year, residency programs may elect to replace in-person interviews with VCIs, or they may utilize VCIs as screening tools to narrow down the applicant pool and for students to rank their preferred programs prior to an in-person interview. By inviting fewer applicants for in-person interviews, travel-associated health risks, financial costs, and missed educational activities would be minimized. Given that many medical students have had academic activities cancelled or postponed due to COVID-19, student opportunities for live clinical experiences should be maximized.

As programs plan for future application cycles beyond COVID-19, they must work to balance competing interests. Videoconferencing interviews allow for improved access to interviewing for applicants of lower socioeconomic classes, improved geographic mobility of applicants, and increased flexibility in accommodating faculty schedules with reduced time away from patient care and research; however, with VCIs one may lose the personal element that comes from the in-person interview, including interactions among applicants, faculty, current residents, and staff on the day of interview, as well as the departmental tour. Additionally, the quality of VCIs may be diminished by technical difficulties and the possibility of distractions, making standardization of the interview experience for applicants challenging.

The COVID-19 pandemic will surely leave its mark on the residency application cycle. We must take time now to collaborate and brainstorm creative solutions to maximize the equity and efficiency of the application process for both residency programs and students. We welcome reader feedback on these ideas and other possible solutions in the form of Letters to the Editor.

Residency application is an arduous experience for many medical students. The National Resident Matching Program reported that US medical school seniors who matched into dermatology applied to a median of 90 programs and attended 9 interviews in 2019.¹ High application and interview travel costs are a disadvantage for applicants from lower socioeconomic backgrounds. We propose that the coronavirus disease 2019 (COVID-19) pandemic should serve as a call to action for dermatology to update and promote a more equitable, time-effective, and cost-efficient residency interview process.

In light of COVID-19, dermatology residency program directors have recommended a holistic application review process, taking into consideration “disparities in strength of applications due to lack of opportunity for students with smaller home programs or in areas more affected by this crisis.”² However, in a 2018 survey of 180 dermatology faculty members, 80% stated that time spent reviewing residency applications was already excessive.³ The Association of American Medical Colleges reported that for medical student applicants with US Medical Licensing Examination Step 1 scores lower than 237 or higher than 251, the value added by submitting one additional application beyond means of 43 (95% confidence interval [CI], 34-53) and 34 (95% CI, 28-41), respectively, is reduced relative to the value added by each application before reaching the point of diminishing returns.⁴ Therefore, we suggest limiting the number of applications per applicant to the upper bounds of the CI for the lower US Medical Licensing Examination Step 1 score (53), facilitating a more detailed review of fewer applications by each program and limiting student expenses.

On May 7, 2020, the Association of American Medical Colleges made a statement strongly encouraging medical school and teaching hospital faculty to conduct interviews through videoconferencing.⁵ Videoconferencing interviews (VCIs) minimize travel-associated health risks, providing a more equitable structure for applicants and programs in areas disproportionately impacted by the pandemic. In the 2018 survey of dermatology faculty members, only 11% believed that applicants interviewing virtually received equal consideration to those interviewing in person; a solution to this problem would be to mandate that all applicants use VCIs during the COVID-19 pandemic.³ This coming year, residency programs may elect to replace in-person interviews with VCIs, or they may utilize VCIs as screening tools to narrow down the applicant pool and for students to rank their preferred programs prior to an in-person interview. By inviting fewer applicants for in-person interviews, travel-associated health risks, financial costs, and missed educational activities would be minimized. Given that many medical students have had academic activities cancelled or postponed due to COVID-19, student opportunities for live clinical experiences should be maximized.

As programs plan for future application cycles beyond COVID-19, they must work to balance competing interests. Videoconferencing interviews allow for improved access to interviewing for applicants of lower socioeconomic classes, improved geographic mobility of applicants, and increased flexibility in accommodating faculty schedules with reduced time away from patient care and research; however, with VCIs one may lose the personal element that comes from the in-person interview, including interactions among applicants, faculty, current residents, and staff on the day of interview, as well as the departmental tour. Additionally, the quality of VCIs may be diminished by technical difficulties and the possibility of distractions, making standardization of the interview experience for applicants challenging.

The COVID-19 pandemic will surely leave its mark on the residency application cycle. We must take time now to collaborate and brainstorm creative solutions to maximize the equity and efficiency of the application process for both residency programs and students. We welcome reader feedback on these ideas and other possible solutions in the form of Letters to the Editor.

Case Report

A 92-year-old Eastern European woman presented to our nail clinic with a history of onychodystrophy and arthralgia of the digits of several months’ duration. Her dermatologic history was notable for irritant hand dermatitis. A prior nail plate clipping with histopathologic examination was negative for fungal elements. Physical examination revealed onychorrhexis of all fingernails as well as onycholysis and subungual hyperkeratosis of the right fourth fingernail. Blue-green staining was incidentally noted on the right second and third fingernails and nail folds (Figure 1). Contact dermoscopy using ultrasound gel revealed translucent areas with sparse pigment, though denser areas had a fine branching pattern (Figure 2). When questioned, the patient reported use of “zelyonka,” a brilliant green solution, to self-treat the nails. Histopathology on repeat nail clippings showed parakeratosis and serum, which was most consistent with her known history of irritant hand dermatitis. Radiographs of the hands revealed osteoarthritis that was most prominent at the distal interphalangeal joints.

Comment

Brilliant green is a triphenylmethane dye commonly used in Eastern Europe and other regions for the treatment of superficial skin infections and onychomycosis.¹ Its use as an antiseptic and wound healing agent has been investigated in the scientific literature since at least the early 20th century.² Brilliant green typically is applied in a 0.1% to 2% ethanol solution.¹ The dye has bactericidal activity against gram-positive organisms, particularly staphylococci and streptococci.^2,3 It has been used for the treatment of fungal skin and nail infections since at least the early 20th century, with anecdotal success.⁴ Although there have been no studies investigating use of brilliant green alone for the treatment of onychomycosis, it is sometimes used in combination with conventional oral agents for this purpose.⁵ Because of its availability, safety, ease of use, and low cost, brilliant green has been promoted as an antiseptic in resource-poor settings.³ The revival of brilliant green and other antiseptic dyes in these settings has been suggested as an alternative to oral antibiotic agents, to which resistance is rising, and as a potential cancer therapy.^6,7 Although brilliant green’s mechanism of action in treating skin infections is unclear, it has been shown to form covalent adducts with thioredoxin reductase 2, a protein conserved from bacteria to humans with an essential function for cellular activity.⁷

Early case studies suggested that brilliant green was beneficial in treating wounds²; however, this indication is controversial. In a guinea pig study, brilliant green was shown to inhibit wound healing and the formation of granulation tissue.⁸ It also should be noted that when used topically, brilliant green may cause skin sensitization, necrotic skin reactions, and permanent staining of clothing. It has no known anti-inflammatory properties and also may cause skin irritation.⁸ Brilliant green may cause blindness if it comes in contact with the eyes.¹

Brilliant green has other potential dermatologic indications. For example, a combination of brilliant green and gentian violet, a related dye, has demonstrated efficacy in the treatment of cutaneous hemangiomas in mouse models by blocking expression of angiopoietin-2.⁷

Dermatologists should be familiar with brilliant green and its common uses as well as adverse effects. Brilliant green is commercially available for a low cost ($5 to $20) in specialty pharmacies or online (eg, Amazon). It is sold alone or in combination with gentian violet and proflavine hemisulfate, and a prescription is not required. Due to its low cost and accessibility, patients may use brilliant green to self-treat dermatologic conditions. Green nails due to staining with brilliant green dye must be distinguished from other etiologies causing green nail discoloration, such as infection with Pseudomonas aeruginosa or Aspergillus, bullous disorders, jaundice, “old” hematomas, nail polish, and other exogenous pigments.

Case Report

A 92-year-old Eastern European woman presented to our nail clinic with a history of onychodystrophy and arthralgia of the digits of several months’ duration. Her dermatologic history was notable for irritant hand dermatitis. A prior nail plate clipping with histopathologic examination was negative for fungal elements. Physical examination revealed onychorrhexis of all fingernails as well as onycholysis and subungual hyperkeratosis of the right fourth fingernail. Blue-green staining was incidentally noted on the right second and third fingernails and nail folds (Figure 1). Contact dermoscopy using ultrasound gel revealed translucent areas with sparse pigment, though denser areas had a fine branching pattern (Figure 2). When questioned, the patient reported use of “zelyonka,” a brilliant green solution, to self-treat the nails. Histopathology on repeat nail clippings showed parakeratosis and serum, which was most consistent with her known history of irritant hand dermatitis. Radiographs of the hands revealed osteoarthritis that was most prominent at the distal interphalangeal joints.

Comment

Brilliant green is a triphenylmethane dye commonly used in Eastern Europe and other regions for the treatment of superficial skin infections and onychomycosis.¹ Its use as an antiseptic and wound healing agent has been investigated in the scientific literature since at least the early 20th century.² Brilliant green typically is applied in a 0.1% to 2% ethanol solution.¹ The dye has bactericidal activity against gram-positive organisms, particularly staphylococci and streptococci.^2,3 It has been used for the treatment of fungal skin and nail infections since at least the early 20th century, with anecdotal success.⁴ Although there have been no studies investigating use of brilliant green alone for the treatment of onychomycosis, it is sometimes used in combination with conventional oral agents for this purpose.⁵ Because of its availability, safety, ease of use, and low cost, brilliant green has been promoted as an antiseptic in resource-poor settings.³ The revival of brilliant green and other antiseptic dyes in these settings has been suggested as an alternative to oral antibiotic agents, to which resistance is rising, and as a potential cancer therapy.^6,7 Although brilliant green’s mechanism of action in treating skin infections is unclear, it has been shown to form covalent adducts with thioredoxin reductase 2, a protein conserved from bacteria to humans with an essential function for cellular activity.⁷

Early case studies suggested that brilliant green was beneficial in treating wounds²; however, this indication is controversial. In a guinea pig study, brilliant green was shown to inhibit wound healing and the formation of granulation tissue.⁸ It also should be noted that when used topically, brilliant green may cause skin sensitization, necrotic skin reactions, and permanent staining of clothing. It has no known anti-inflammatory properties and also may cause skin irritation.⁸ Brilliant green may cause blindness if it comes in contact with the eyes.¹

Brilliant green has other potential dermatologic indications. For example, a combination of brilliant green and gentian violet, a related dye, has demonstrated efficacy in the treatment of cutaneous hemangiomas in mouse models by blocking expression of angiopoietin-2.⁷

Dermatologists should be familiar with brilliant green and its common uses as well as adverse effects. Brilliant green is commercially available for a low cost ($5 to $20) in specialty pharmacies or online (eg, Amazon). It is sold alone or in combination with gentian violet and proflavine hemisulfate, and a prescription is not required. Due to its low cost and accessibility, patients may use brilliant green to self-treat dermatologic conditions. Green nails due to staining with brilliant green dye must be distinguished from other etiologies causing green nail discoloration, such as infection with Pseudomonas aeruginosa or Aspergillus, bullous disorders, jaundice, “old” hematomas, nail polish, and other exogenous pigments.

Case Report

A 92-year-old Eastern European woman presented to our nail clinic with a history of onychodystrophy and arthralgia of the digits of several months’ duration. Her dermatologic history was notable for irritant hand dermatitis. A prior nail plate clipping with histopathologic examination was negative for fungal elements. Physical examination revealed onychorrhexis of all fingernails as well as onycholysis and subungual hyperkeratosis of the right fourth fingernail. Blue-green staining was incidentally noted on the right second and third fingernails and nail folds (Figure 1). Contact dermoscopy using ultrasound gel revealed translucent areas with sparse pigment, though denser areas had a fine branching pattern (Figure 2). When questioned, the patient reported use of “zelyonka,” a brilliant green solution, to self-treat the nails. Histopathology on repeat nail clippings showed parakeratosis and serum, which was most consistent with her known history of irritant hand dermatitis. Radiographs of the hands revealed osteoarthritis that was most prominent at the distal interphalangeal joints.

Comment

Brilliant green is a triphenylmethane dye commonly used in Eastern Europe and other regions for the treatment of superficial skin infections and onychomycosis.¹ Its use as an antiseptic and wound healing agent has been investigated in the scientific literature since at least the early 20th century.² Brilliant green typically is applied in a 0.1% to 2% ethanol solution.¹ The dye has bactericidal activity against gram-positive organisms, particularly staphylococci and streptococci.^2,3 It has been used for the treatment of fungal skin and nail infections since at least the early 20th century, with anecdotal success.⁴ Although there have been no studies investigating use of brilliant green alone for the treatment of onychomycosis, it is sometimes used in combination with conventional oral agents for this purpose.⁵ Because of its availability, safety, ease of use, and low cost, brilliant green has been promoted as an antiseptic in resource-poor settings.³ The revival of brilliant green and other antiseptic dyes in these settings has been suggested as an alternative to oral antibiotic agents, to which resistance is rising, and as a potential cancer therapy.^6,7 Although brilliant green’s mechanism of action in treating skin infections is unclear, it has been shown to form covalent adducts with thioredoxin reductase 2, a protein conserved from bacteria to humans with an essential function for cellular activity.⁷

Early case studies suggested that brilliant green was beneficial in treating wounds²; however, this indication is controversial. In a guinea pig study, brilliant green was shown to inhibit wound healing and the formation of granulation tissue.⁸ It also should be noted that when used topically, brilliant green may cause skin sensitization, necrotic skin reactions, and permanent staining of clothing. It has no known anti-inflammatory properties and also may cause skin irritation.⁸ Brilliant green may cause blindness if it comes in contact with the eyes.¹

Brilliant green has other potential dermatologic indications. For example, a combination of brilliant green and gentian violet, a related dye, has demonstrated efficacy in the treatment of cutaneous hemangiomas in mouse models by blocking expression of angiopoietin-2.⁷

Dermatologists should be familiar with brilliant green and its common uses as well as adverse effects. Brilliant green is commercially available for a low cost ($5 to $20) in specialty pharmacies or online (eg, Amazon). It is sold alone or in combination with gentian violet and proflavine hemisulfate, and a prescription is not required. Due to its low cost and accessibility, patients may use brilliant green to self-treat dermatologic conditions. Green nails due to staining with brilliant green dye must be distinguished from other etiologies causing green nail discoloration, such as infection with Pseudomonas aeruginosa or Aspergillus, bullous disorders, jaundice, “old” hematomas, nail polish, and other exogenous pigments.

Practice Gap

Anxiety is common in patients undergoing surgery with general anesthesia and may be exacerbated in patients undergoing dermatologic surgery with local anesthesia. Apprehension might be worse for nail surgery patients because the nail unit is highly innervated and vascular. Many patients fear the anesthetic injections, and there often is pain postoperatively. Perioperative anxiety correlates with increased postoperative pain,¹ analgesic use,² and delayed recovery.³ Several alternatives have been proposed to decrease perioperative anxiety, including nonpharmacologic interventions such as using educational videos, personalized music, hand holding, art activities, and virtual reality, as well as pharmacologic interventions such as benzodiazepines. However, these techniques have not been well studied for nail surgery.

The Technique

Patients generally are anxious about nail surgery secondary to the pain associated with the local anesthetic infiltration; hence, it is crucial to decrease anxiety during this initial step. In our practice, we provide patients with a palm-sized stress ball made of closed-cell polyurethane foam rubber before surgery. Patients are then instructed to hold the stress ball with the free hand and squeeze it whenever they feel anxious or when they feel any discomfort related to the procedure (Figure). A variety of balls can be bought for less than $1 each, thus making it a cost-effective option.

Practice Implications

Holding a stress ball has been found to reduce both pain and anxiety in patients undergoing conscious surgery.⁴ Furthermore, squeezing a stress ball perioperatively may increase feelings of empowerment, given that patients have direct control over the object, which in turn may have a positive effect on anxiety and patient satisfaction without interfering with the surgical procedure.⁵ Holding a stress ball is a safe, widely accessible, and inexpensive technique that may aid in decreasing patients’ anxiety related to nail surgery. Nonetheless, controlled clinical trials assessing the efficacy of this method in reducing anxiety related to nail surgery are needed to determine its benefit compared to other methods.

Practice Gap

Anxiety is common in patients undergoing surgery with general anesthesia and may be exacerbated in patients undergoing dermatologic surgery with local anesthesia. Apprehension might be worse for nail surgery patients because the nail unit is highly innervated and vascular. Many patients fear the anesthetic injections, and there often is pain postoperatively. Perioperative anxiety correlates with increased postoperative pain,¹ analgesic use,² and delayed recovery.³ Several alternatives have been proposed to decrease perioperative anxiety, including nonpharmacologic interventions such as using educational videos, personalized music, hand holding, art activities, and virtual reality, as well as pharmacologic interventions such as benzodiazepines. However, these techniques have not been well studied for nail surgery.

The Technique

Patients generally are anxious about nail surgery secondary to the pain associated with the local anesthetic infiltration; hence, it is crucial to decrease anxiety during this initial step. In our practice, we provide patients with a palm-sized stress ball made of closed-cell polyurethane foam rubber before surgery. Patients are then instructed to hold the stress ball with the free hand and squeeze it whenever they feel anxious or when they feel any discomfort related to the procedure (Figure). A variety of balls can be bought for less than $1 each, thus making it a cost-effective option.

Practice Implications

Holding a stress ball has been found to reduce both pain and anxiety in patients undergoing conscious surgery.⁴ Furthermore, squeezing a stress ball perioperatively may increase feelings of empowerment, given that patients have direct control over the object, which in turn may have a positive effect on anxiety and patient satisfaction without interfering with the surgical procedure.⁵ Holding a stress ball is a safe, widely accessible, and inexpensive technique that may aid in decreasing patients’ anxiety related to nail surgery. Nonetheless, controlled clinical trials assessing the efficacy of this method in reducing anxiety related to nail surgery are needed to determine its benefit compared to other methods.

Practice Gap

Anxiety is common in patients undergoing surgery with general anesthesia and may be exacerbated in patients undergoing dermatologic surgery with local anesthesia. Apprehension might be worse for nail surgery patients because the nail unit is highly innervated and vascular. Many patients fear the anesthetic injections, and there often is pain postoperatively. Perioperative anxiety correlates with increased postoperative pain,¹ analgesic use,² and delayed recovery.³ Several alternatives have been proposed to decrease perioperative anxiety, including nonpharmacologic interventions such as using educational videos, personalized music, hand holding, art activities, and virtual reality, as well as pharmacologic interventions such as benzodiazepines. However, these techniques have not been well studied for nail surgery.

The Technique

Patients generally are anxious about nail surgery secondary to the pain associated with the local anesthetic infiltration; hence, it is crucial to decrease anxiety during this initial step. In our practice, we provide patients with a palm-sized stress ball made of closed-cell polyurethane foam rubber before surgery. Patients are then instructed to hold the stress ball with the free hand and squeeze it whenever they feel anxious or when they feel any discomfort related to the procedure (Figure). A variety of balls can be bought for less than $1 each, thus making it a cost-effective option.

Practice Implications

Holding a stress ball has been found to reduce both pain and anxiety in patients undergoing conscious surgery.⁴ Furthermore, squeezing a stress ball perioperatively may increase feelings of empowerment, given that patients have direct control over the object, which in turn may have a positive effect on anxiety and patient satisfaction without interfering with the surgical procedure.⁵ Holding a stress ball is a safe, widely accessible, and inexpensive technique that may aid in decreasing patients’ anxiety related to nail surgery. Nonetheless, controlled clinical trials assessing the efficacy of this method in reducing anxiety related to nail surgery are needed to determine its benefit compared to other methods.

Handwashing with antimicrobial soaps or alcohol-based sanitizers is an effective measure in preventing microbial disease transmission. In the context of coronavirus disease 2019 (COVID-19) prevention, the World Health Organization and Centers for Disease Control and Prevention have recommended handwashing with soap and water after coughing/sneezing, visiting a public place, touching surfaces outside the home, and taking care of a sick person(s), as well as before and after eating. When soap and water are not available, alcohol-based sanitizers may be used.^1,2

Irritant contact dermatitis (ICD) is most commonly associated with wet work and is frequently seen in health care workers in relation to hand hygiene, with survey-based studies reporting 25% to 55% of nurses affected.^3-5 In a prospective study (N=102), health care workers who washed their hands more than 10 times per day were55% more likely to develop hand dermatitis.⁶ Frequent ICD of the hands has been reported in Chinese health care workers in association with COVID-19.⁷ Handwashing and/or glove wearing may be newly prioritized by workers who handle frequently touched goods and surfaces, such as flight attendants (Figure). Patients with obsessive-compulsive disorder may be another vulnerable population.⁸

Propensity for ICD is a limiting factor in hand hygiene adherence.¹⁷ In a double-blind randomized trial (N=54), scheduled use of an oil-containing lotion was shown to increase compliance with hand hygiene protocols in health care workers by preventing cracks, scaling, and pain.¹⁸ Using sanitizers containing humectants (eg, aloe vera gel) or moisturizers with petrolatum, liquid paraffin, glycerin, or mineral oil have all been shown to decrease the incidence of ICD in frequent handwashers.^19,20 Thorough hand drying also is important in preventing dermatitis. Drying with disposable paper towels is preferred over automated air dryers to prevent aerosolization of microbes.²¹ Because latex has been implicated in development of ICD, use of latex-free gloves is recommended.²²

Alcohol-based sanitizer is not only an effective virucidal agent but also is less likely to cause ICD, therefore promoting hand hygiene adherence. Handwashing with soap still is necessary when hands are visibly dirty but should be performed less frequently if feasible. Hand hygiene and emollient usage education is important for physicians and patients alike, particularly during the COVID-19 crisis.

Handwashing with antimicrobial soaps or alcohol-based sanitizers is an effective measure in preventing microbial disease transmission. In the context of coronavirus disease 2019 (COVID-19) prevention, the World Health Organization and Centers for Disease Control and Prevention have recommended handwashing with soap and water after coughing/sneezing, visiting a public place, touching surfaces outside the home, and taking care of a sick person(s), as well as before and after eating. When soap and water are not available, alcohol-based sanitizers may be used.^1,2

Irritant contact dermatitis (ICD) is most commonly associated with wet work and is frequently seen in health care workers in relation to hand hygiene, with survey-based studies reporting 25% to 55% of nurses affected.^3-5 In a prospective study (N=102), health care workers who washed their hands more than 10 times per day were55% more likely to develop hand dermatitis.⁶ Frequent ICD of the hands has been reported in Chinese health care workers in association with COVID-19.⁷ Handwashing and/or glove wearing may be newly prioritized by workers who handle frequently touched goods and surfaces, such as flight attendants (Figure). Patients with obsessive-compulsive disorder may be another vulnerable population.⁸

Propensity for ICD is a limiting factor in hand hygiene adherence.¹⁷ In a double-blind randomized trial (N=54), scheduled use of an oil-containing lotion was shown to increase compliance with hand hygiene protocols in health care workers by preventing cracks, scaling, and pain.¹⁸ Using sanitizers containing humectants (eg, aloe vera gel) or moisturizers with petrolatum, liquid paraffin, glycerin, or mineral oil have all been shown to decrease the incidence of ICD in frequent handwashers.^19,20 Thorough hand drying also is important in preventing dermatitis. Drying with disposable paper towels is preferred over automated air dryers to prevent aerosolization of microbes.²¹ Because latex has been implicated in development of ICD, use of latex-free gloves is recommended.²²

Alcohol-based sanitizer is not only an effective virucidal agent but also is less likely to cause ICD, therefore promoting hand hygiene adherence. Handwashing with soap still is necessary when hands are visibly dirty but should be performed less frequently if feasible. Hand hygiene and emollient usage education is important for physicians and patients alike, particularly during the COVID-19 crisis.

Handwashing with antimicrobial soaps or alcohol-based sanitizers is an effective measure in preventing microbial disease transmission. In the context of coronavirus disease 2019 (COVID-19) prevention, the World Health Organization and Centers for Disease Control and Prevention have recommended handwashing with soap and water after coughing/sneezing, visiting a public place, touching surfaces outside the home, and taking care of a sick person(s), as well as before and after eating. When soap and water are not available, alcohol-based sanitizers may be used.^1,2

Irritant contact dermatitis (ICD) is most commonly associated with wet work and is frequently seen in health care workers in relation to hand hygiene, with survey-based studies reporting 25% to 55% of nurses affected.^3-5 In a prospective study (N=102), health care workers who washed their hands more than 10 times per day were55% more likely to develop hand dermatitis.⁶ Frequent ICD of the hands has been reported in Chinese health care workers in association with COVID-19.⁷ Handwashing and/or glove wearing may be newly prioritized by workers who handle frequently touched goods and surfaces, such as flight attendants (Figure). Patients with obsessive-compulsive disorder may be another vulnerable population.⁸

Propensity for ICD is a limiting factor in hand hygiene adherence.¹⁷ In a double-blind randomized trial (N=54), scheduled use of an oil-containing lotion was shown to increase compliance with hand hygiene protocols in health care workers by preventing cracks, scaling, and pain.¹⁸ Using sanitizers containing humectants (eg, aloe vera gel) or moisturizers with petrolatum, liquid paraffin, glycerin, or mineral oil have all been shown to decrease the incidence of ICD in frequent handwashers.^19,20 Thorough hand drying also is important in preventing dermatitis. Drying with disposable paper towels is preferred over automated air dryers to prevent aerosolization of microbes.²¹ Because latex has been implicated in development of ICD, use of latex-free gloves is recommended.²²

Alcohol-based sanitizer is not only an effective virucidal agent but also is less likely to cause ICD, therefore promoting hand hygiene adherence. Handwashing with soap still is necessary when hands are visibly dirty but should be performed less frequently if feasible. Hand hygiene and emollient usage education is important for physicians and patients alike, particularly during the COVID-19 crisis.

To the Editor:

The diagnosis and treatment of nail conditions are necessary competencies for board-certified dermatologists, but appropriate education often is lacking.¹ The American Academy of Dermatology (AAD) annual meeting is one of the largest and most highly attended dermatology educational conferences worldwide. We sought to determine the number of hours dedicated to nail-related topics at the AAD annual meetings from 2013 to 2019.

We accessed programs from the AAD annual meetings archive online (https://www.aad.org/meetings/previous-meetings-archive), and we used hair and psoriasis content for comparison. Event titles and descriptions were searched for nail-related content (using search terms nail, onychia, and onycho), hair-related content (hair, alopecia, trichosis, hirsutism), and psoriasis content (psoriasis). Data acquired for each event included the date, hours, title, and event type (eg, forum, course, focus session, symposium, discussion group, workshop, plenary session).

The number of hours dedicated to nail education consistently lagged behind those related to hair and psoriasis content during the study period (Figure 1). According to the AAD, the conference runs Friday to Tuesday with higher attendance Friday to Sunday (Tim Moses, personal communication, July 9, 2019). Lectures during the weekend are likely to have a broader reach than lectures on Monday and Tuesday. The proportion of nail content during weekend prime time slots was similar to that of hair and psoriasis (Figure 2). Plenary sessions often are presented by renowned experts on hot topics in dermatology. Notably, hair (2014-2015) and psoriasis (2015-2017) content were represented in the plenary sessions during the study period, while nail content was not featured.

A limitation of this study was the lack of online data available for AAD annual meetings before 2013, so we were unable to characterize any long-term trends. Furthermore, we were unable to assess the educational reach of these sessions, as data on attendance are lacking.

This study demonstrates a paucity of nail-related content at the AAD annual meetings. The introduction of the “Hands-on: Nail Surgery” in 2015 is an important step forward to diminish the knowledge gap in the diagnosis of various nail diseases and malignancies. We recommend increasing the number of hours and overall content of didactic nail sessions at the AAD annual meeting to further the knowledge and procedural skills of dermatologists in caring for patients with nail disorders.

To the Editor:

The diagnosis and treatment of nail conditions are necessary competencies for board-certified dermatologists, but appropriate education often is lacking.¹ The American Academy of Dermatology (AAD) annual meeting is one of the largest and most highly attended dermatology educational conferences worldwide. We sought to determine the number of hours dedicated to nail-related topics at the AAD annual meetings from 2013 to 2019.

We accessed programs from the AAD annual meetings archive online (https://www.aad.org/meetings/previous-meetings-archive), and we used hair and psoriasis content for comparison. Event titles and descriptions were searched for nail-related content (using search terms nail, onychia, and onycho), hair-related content (hair, alopecia, trichosis, hirsutism), and psoriasis content (psoriasis). Data acquired for each event included the date, hours, title, and event type (eg, forum, course, focus session, symposium, discussion group, workshop, plenary session).

The number of hours dedicated to nail education consistently lagged behind those related to hair and psoriasis content during the study period (Figure 1). According to the AAD, the conference runs Friday to Tuesday with higher attendance Friday to Sunday (Tim Moses, personal communication, July 9, 2019). Lectures during the weekend are likely to have a broader reach than lectures on Monday and Tuesday. The proportion of nail content during weekend prime time slots was similar to that of hair and psoriasis (Figure 2). Plenary sessions often are presented by renowned experts on hot topics in dermatology. Notably, hair (2014-2015) and psoriasis (2015-2017) content were represented in the plenary sessions during the study period, while nail content was not featured.

A limitation of this study was the lack of online data available for AAD annual meetings before 2013, so we were unable to characterize any long-term trends. Furthermore, we were unable to assess the educational reach of these sessions, as data on attendance are lacking.

This study demonstrates a paucity of nail-related content at the AAD annual meetings. The introduction of the “Hands-on: Nail Surgery” in 2015 is an important step forward to diminish the knowledge gap in the diagnosis of various nail diseases and malignancies. We recommend increasing the number of hours and overall content of didactic nail sessions at the AAD annual meeting to further the knowledge and procedural skills of dermatologists in caring for patients with nail disorders.

To the Editor:

The diagnosis and treatment of nail conditions are necessary competencies for board-certified dermatologists, but appropriate education often is lacking.¹ The American Academy of Dermatology (AAD) annual meeting is one of the largest and most highly attended dermatology educational conferences worldwide. We sought to determine the number of hours dedicated to nail-related topics at the AAD annual meetings from 2013 to 2019.

We accessed programs from the AAD annual meetings archive online (https://www.aad.org/meetings/previous-meetings-archive), and we used hair and psoriasis content for comparison. Event titles and descriptions were searched for nail-related content (using search terms nail, onychia, and onycho), hair-related content (hair, alopecia, trichosis, hirsutism), and psoriasis content (psoriasis). Data acquired for each event included the date, hours, title, and event type (eg, forum, course, focus session, symposium, discussion group, workshop, plenary session).

The number of hours dedicated to nail education consistently lagged behind those related to hair and psoriasis content during the study period (Figure 1). According to the AAD, the conference runs Friday to Tuesday with higher attendance Friday to Sunday (Tim Moses, personal communication, July 9, 2019). Lectures during the weekend are likely to have a broader reach than lectures on Monday and Tuesday. The proportion of nail content during weekend prime time slots was similar to that of hair and psoriasis (Figure 2). Plenary sessions often are presented by renowned experts on hot topics in dermatology. Notably, hair (2014-2015) and psoriasis (2015-2017) content were represented in the plenary sessions during the study period, while nail content was not featured.

A limitation of this study was the lack of online data available for AAD annual meetings before 2013, so we were unable to characterize any long-term trends. Furthermore, we were unable to assess the educational reach of these sessions, as data on attendance are lacking.

This study demonstrates a paucity of nail-related content at the AAD annual meetings. The introduction of the “Hands-on: Nail Surgery” in 2015 is an important step forward to diminish the knowledge gap in the diagnosis of various nail diseases and malignancies. We recommend increasing the number of hours and overall content of didactic nail sessions at the AAD annual meeting to further the knowledge and procedural skills of dermatologists in caring for patients with nail disorders.

To the Editor:

Nail biopsy is an important surgical procedure for diagnosis of nail pathology. YouTube has become a potential instrument for physicians and patients to learn about medical procedures.^1,2 However, the sources, content, and quality of the information available have not been fully studied or characterized. Our objective was to analyze the efficiency of information and quality of YouTube videos on nail biopsies. We hypothesized that the quality of patient education and physician training videos would be unrepresentative on YouTube.

The term nail biopsy was searched on January 29, 2019, and filtered by relevance and rating using the default YouTube algorithm. Data were collected from the top 40 hits for the search term and filter coupling. All videos were viewed and sorted for nail biopsy procedures, and then those videos were categorized as being produced by a physician or other health care provider. The US medical board status of each physician videographer was determined using the American Board of Medical Specialties database.³ DISCERN criteria for assessing consumer health care information⁴ were used to interpret the videos by researchers (S.I. and S.R.L.) in this study.

From the queried search term collection, only 10 videos (1,023,423 combined views) were analyzed in this study (eTable). Although the other resulting videos were tagged as nail biopsy, they were excluded due to irrelevant content (eg, patient blogs, PowerPoints, nail avulsions). The mean age of the videos was 4 years (range, 4 days to 11 years), with a mean video length of 3.30 minutes (range, 49 seconds to 9.03 minutes). Four of 10 videos were performed for longitudinal melanonychia, and 5 of 10 videos were performed for melanonychia, clinically consistent with subungual hematoma. Dermatologists, plastic surgeons, and podiatrists produced the majority of the nail biopsy videos. The overall mean DISCERN rating was 1.60/5.00 (range, 1–3), meaning that the quality of content on nail biopsies was poor. This low DISCERN score signifies poor consumer health information. Video 2 (published in 2015) received a DISCERN score of 2 and received almost 1 million views, which is likely because the specific channel has a well-established subscriber pool (4.9 million subscribers). The highest DISCERN score of 3, demonstrating a tangential shave biopsy, was given to video 4 (published in 2010) and only received about 17,400 views (56 subscribers). Additionally, many videos lacked important information about the procedure. For instance, only 3 of 10 videos demonstrated the anesthetic technique and only 5 videos showed repair methods.

To the Editor:

Nail biopsy is an important surgical procedure for diagnosis of nail pathology. YouTube has become a potential instrument for physicians and patients to learn about medical procedures.^1,2 However, the sources, content, and quality of the information available have not been fully studied or characterized. Our objective was to analyze the efficiency of information and quality of YouTube videos on nail biopsies. We hypothesized that the quality of patient education and physician training videos would be unrepresentative on YouTube.

The term nail biopsy was searched on January 29, 2019, and filtered by relevance and rating using the default YouTube algorithm. Data were collected from the top 40 hits for the search term and filter coupling. All videos were viewed and sorted for nail biopsy procedures, and then those videos were categorized as being produced by a physician or other health care provider. The US medical board status of each physician videographer was determined using the American Board of Medical Specialties database.³ DISCERN criteria for assessing consumer health care information⁴ were used to interpret the videos by researchers (S.I. and S.R.L.) in this study.

From the queried search term collection, only 10 videos (1,023,423 combined views) were analyzed in this study (eTable). Although the other resulting videos were tagged as nail biopsy, they were excluded due to irrelevant content (eg, patient blogs, PowerPoints, nail avulsions). The mean age of the videos was 4 years (range, 4 days to 11 years), with a mean video length of 3.30 minutes (range, 49 seconds to 9.03 minutes). Four of 10 videos were performed for longitudinal melanonychia, and 5 of 10 videos were performed for melanonychia, clinically consistent with subungual hematoma. Dermatologists, plastic surgeons, and podiatrists produced the majority of the nail biopsy videos. The overall mean DISCERN rating was 1.60/5.00 (range, 1–3), meaning that the quality of content on nail biopsies was poor. This low DISCERN score signifies poor consumer health information. Video 2 (published in 2015) received a DISCERN score of 2 and received almost 1 million views, which is likely because the specific channel has a well-established subscriber pool (4.9 million subscribers). The highest DISCERN score of 3, demonstrating a tangential shave biopsy, was given to video 4 (published in 2010) and only received about 17,400 views (56 subscribers). Additionally, many videos lacked important information about the procedure. For instance, only 3 of 10 videos demonstrated the anesthetic technique and only 5 videos showed repair methods.

To the Editor:

Nail biopsy is an important surgical procedure for diagnosis of nail pathology. YouTube has become a potential instrument for physicians and patients to learn about medical procedures.^1,2 However, the sources, content, and quality of the information available have not been fully studied or characterized. Our objective was to analyze the efficiency of information and quality of YouTube videos on nail biopsies. We hypothesized that the quality of patient education and physician training videos would be unrepresentative on YouTube.

The term nail biopsy was searched on January 29, 2019, and filtered by relevance and rating using the default YouTube algorithm. Data were collected from the top 40 hits for the search term and filter coupling. All videos were viewed and sorted for nail biopsy procedures, and then those videos were categorized as being produced by a physician or other health care provider. The US medical board status of each physician videographer was determined using the American Board of Medical Specialties database.³ DISCERN criteria for assessing consumer health care information⁴ were used to interpret the videos by researchers (S.I. and S.R.L.) in this study.

From the queried search term collection, only 10 videos (1,023,423 combined views) were analyzed in this study (eTable). Although the other resulting videos were tagged as nail biopsy, they were excluded due to irrelevant content (eg, patient blogs, PowerPoints, nail avulsions). The mean age of the videos was 4 years (range, 4 days to 11 years), with a mean video length of 3.30 minutes (range, 49 seconds to 9.03 minutes). Four of 10 videos were performed for longitudinal melanonychia, and 5 of 10 videos were performed for melanonychia, clinically consistent with subungual hematoma. Dermatologists, plastic surgeons, and podiatrists produced the majority of the nail biopsy videos. The overall mean DISCERN rating was 1.60/5.00 (range, 1–3), meaning that the quality of content on nail biopsies was poor. This low DISCERN score signifies poor consumer health information. Video 2 (published in 2015) received a DISCERN score of 2 and received almost 1 million views, which is likely because the specific channel has a well-established subscriber pool (4.9 million subscribers). The highest DISCERN score of 3, demonstrating a tangential shave biopsy, was given to video 4 (published in 2010) and only received about 17,400 views (56 subscribers). Additionally, many videos lacked important information about the procedure. For instance, only 3 of 10 videos demonstrated the anesthetic technique and only 5 videos showed repair methods.

Beau lines are palpable transverse depressions on the dorsal aspect of the nail plate that result from a temporary slowing of nail plate production by the proximal nail matrix. Onychomadesis is a separation of the proximal nail plate from the distal nail plate leading to shedding of the nail. It occurs due to a complete growth arrest in the nail matrix and is thought to be on a continuum with Beau lines. The etiologies of these 2 conditions overlap and include trauma, inflammatory diseases, systemic illnesses, hereditary conditions, and infections.^1-5 In almost all cases of both conditions, normal nail plate production ensues upon identification and removal of the inciting agent or recuperation from the causal illness.^3,4,6 Beau lines will move distally as the nail grows out and can be clipped. In onychomadesis, the affected nails will be shed with time. Resolution of these nail defects can be estimated from average nail growth rates (1 mm/mo for fingernails and 2–3 mm/mo for toenails).⁷

Retronychia is defined as a proximal ingrowing of the nail plate into the ventral surface of the proximal nail fold.^4,6 It is thought to occur via vertical progression of the nail plate into the proximal nail fold, repetitive nail matrix trauma, or shearing forces, resulting in inflammation that leads to nail plate stacking.^8,9 Although conservative treatment using topical corticosteroids may be attempted, proximal nail plate avulsion typically is required for treatment.¹⁰

Braswell et al¹ suggested a unifying hypothesis for a common pathophysiologic basis for these 3 conditions; that is, nail matrix injury results in slowing and/or cessation of nail plate production, followed by recommencement of nail plate production by the nail matrix after removal of the insult. We report a case of a patient presenting with concurrent Beau lines, onychomadesis, and retronychia following scurvy, thus supporting the hypothesis that these 3 nail conditions lie on a continuum.

Case Report

A 41-year-old woman with a history of thyroiditis, gastroesophageal reflux disease, endometriosis, osteoarthritis, gastric ulcer, pancreatitis, fatty liver, and polycystic ovarian syndrome presented with lines on the toenails and no growth of the right second toenail of several months’ duration. She denied any pain or prior trauma to the nails, participation in sports activities, or wearing tight or high-heeled shoes. She had presented 6 months prior for evaluation of perifollicular erythema on the posterior thighs, legs, and abdomen, as well as gingival bleeding.¹¹ At that time, one of the authors (S.R.L.) found that she was vitamin C deficient, and a diagnosis of scurvy was made. The rash and gingival bleeding resolved with vitamin C supplementation.¹¹

At the current presentation, physical examination revealed transverse grooves involving several fingernails but most evident on the left thumbnail (Figure, A). The grooves did not span the entire breadth of the nail, which was consistent with Beau lines. Several toenails had parallel transverse grooves spanning the entire width of the nail plate such that the proximal nail plate was discontinuous with the distal nail plate, which was consistent with onychomadesis (Figure, B). The right second toenail was yellow and thickened with layered nail plates, indicative of retronychia (Figure, B). Histopathology of a nail plate clipping from the right second toenail was negative for fungal hyphae, and a radiograph was negative for bony changes or exostosis.

Comment

The nail matrix is responsible for nail plate production, and the newly formed nail plate then moves outward over the nail bed. It is hypothesized that the pathophysiologic basis for Beau lines, onychomadesis, and retronychia lies on a continuum such that all 3 conditions are caused by an insult to the nail matrix that results in slowing and/or halting of nail plate growth. Beau lines result from slowing or disruption in cell growth from the nail matrix, whereas onychomadesis is associated with a complete halt in nail plate production.^1,3 In retronychia, the new nail growing from the matrix pushes the old one upward, interrupting the longitudinal growth of the nail and leading to nail plate stacking.¹⁰

Our patient presented with concurrent Beau lines, onychomadesis, and retronychia. Although Beau lines and onychomadesis have been reported together in some instances,^12-14 retronychia is not commonly reported with either of these conditions. The exact incidence of each condition has not been studied, but Beau lines are relatively common, onychomadesis is less common, and retronychia is seen infrequently; therefore, the concurrent presentation of these 3 conditions in the same patient is exceedingly rare. Thus, it was most likely that one etiology accounted for all 3 nail findings.

Because the patient had been diagnosed with scurvy 6 months prior to presentation, we hypothesized that the associated vitamin C deficiency caused a systemic insult to the nail matrix, which resulted in cessation of nail growth. The mechanism of nail matrix arrest in the setting of systemic disease is thought to be due to inhibition of cellular proliferation or a change in the quality of the newly manufactured nail plate, which becomes thinner and more dystrophic.¹⁵ Vitamin C (ascorbic acid) deficiency causes scurvy, which is characterized by cutaneous signs such as perifollicular hemorrhage and purpura, corkscrew hairs, bruising, gingivitis, arthralgia, and impaired wound healing.¹⁶ These clinical manifestations are due to impaired collagen synthesis and disordered connective tissue. Ascorbic acid also is involved in fatty acid transport, neurotransmitter synthesis, prostaglandin metabolism, and nitric oxide synthesis.¹⁷ Ascorbic acid has not been studied for its role in nail plate synthesis¹⁸; however, given the role that ascorbic acid plays in a myriad of biologic processes, the deficiency associated with scurvy likely had a considerable systemic effect in our patient that halted nail plate synthesis and resulted in the concurrent presentation of Beau lines, onychomadesis, and retronychia.

Beau lines are palpable transverse depressions on the dorsal aspect of the nail plate that result from a temporary slowing of nail plate production by the proximal nail matrix. Onychomadesis is a separation of the proximal nail plate from the distal nail plate leading to shedding of the nail. It occurs due to a complete growth arrest in the nail matrix and is thought to be on a continuum with Beau lines. The etiologies of these 2 conditions overlap and include trauma, inflammatory diseases, systemic illnesses, hereditary conditions, and infections.^1-5 In almost all cases of both conditions, normal nail plate production ensues upon identification and removal of the inciting agent or recuperation from the causal illness.^3,4,6 Beau lines will move distally as the nail grows out and can be clipped. In onychomadesis, the affected nails will be shed with time. Resolution of these nail defects can be estimated from average nail growth rates (1 mm/mo for fingernails and 2–3 mm/mo for toenails).⁷

Retronychia is defined as a proximal ingrowing of the nail plate into the ventral surface of the proximal nail fold.^4,6 It is thought to occur via vertical progression of the nail plate into the proximal nail fold, repetitive nail matrix trauma, or shearing forces, resulting in inflammation that leads to nail plate stacking.^8,9 Although conservative treatment using topical corticosteroids may be attempted, proximal nail plate avulsion typically is required for treatment.¹⁰

Braswell et al¹ suggested a unifying hypothesis for a common pathophysiologic basis for these 3 conditions; that is, nail matrix injury results in slowing and/or cessation of nail plate production, followed by recommencement of nail plate production by the nail matrix after removal of the insult. We report a case of a patient presenting with concurrent Beau lines, onychomadesis, and retronychia following scurvy, thus supporting the hypothesis that these 3 nail conditions lie on a continuum.

Case Report

A 41-year-old woman with a history of thyroiditis, gastroesophageal reflux disease, endometriosis, osteoarthritis, gastric ulcer, pancreatitis, fatty liver, and polycystic ovarian syndrome presented with lines on the toenails and no growth of the right second toenail of several months’ duration. She denied any pain or prior trauma to the nails, participation in sports activities, or wearing tight or high-heeled shoes. She had presented 6 months prior for evaluation of perifollicular erythema on the posterior thighs, legs, and abdomen, as well as gingival bleeding.¹¹ At that time, one of the authors (S.R.L.) found that she was vitamin C deficient, and a diagnosis of scurvy was made. The rash and gingival bleeding resolved with vitamin C supplementation.¹¹

At the current presentation, physical examination revealed transverse grooves involving several fingernails but most evident on the left thumbnail (Figure, A). The grooves did not span the entire breadth of the nail, which was consistent with Beau lines. Several toenails had parallel transverse grooves spanning the entire width of the nail plate such that the proximal nail plate was discontinuous with the distal nail plate, which was consistent with onychomadesis (Figure, B). The right second toenail was yellow and thickened with layered nail plates, indicative of retronychia (Figure, B). Histopathology of a nail plate clipping from the right second toenail was negative for fungal hyphae, and a radiograph was negative for bony changes or exostosis.

Comment

The nail matrix is responsible for nail plate production, and the newly formed nail plate then moves outward over the nail bed. It is hypothesized that the pathophysiologic basis for Beau lines, onychomadesis, and retronychia lies on a continuum such that all 3 conditions are caused by an insult to the nail matrix that results in slowing and/or halting of nail plate growth. Beau lines result from slowing or disruption in cell growth from the nail matrix, whereas onychomadesis is associated with a complete halt in nail plate production.^1,3 In retronychia, the new nail growing from the matrix pushes the old one upward, interrupting the longitudinal growth of the nail and leading to nail plate stacking.¹⁰

Our patient presented with concurrent Beau lines, onychomadesis, and retronychia. Although Beau lines and onychomadesis have been reported together in some instances,^12-14 retronychia is not commonly reported with either of these conditions. The exact incidence of each condition has not been studied, but Beau lines are relatively common, onychomadesis is less common, and retronychia is seen infrequently; therefore, the concurrent presentation of these 3 conditions in the same patient is exceedingly rare. Thus, it was most likely that one etiology accounted for all 3 nail findings.

Because the patient had been diagnosed with scurvy 6 months prior to presentation, we hypothesized that the associated vitamin C deficiency caused a systemic insult to the nail matrix, which resulted in cessation of nail growth. The mechanism of nail matrix arrest in the setting of systemic disease is thought to be due to inhibition of cellular proliferation or a change in the quality of the newly manufactured nail plate, which becomes thinner and more dystrophic.¹⁵ Vitamin C (ascorbic acid) deficiency causes scurvy, which is characterized by cutaneous signs such as perifollicular hemorrhage and purpura, corkscrew hairs, bruising, gingivitis, arthralgia, and impaired wound healing.¹⁶ These clinical manifestations are due to impaired collagen synthesis and disordered connective tissue. Ascorbic acid also is involved in fatty acid transport, neurotransmitter synthesis, prostaglandin metabolism, and nitric oxide synthesis.¹⁷ Ascorbic acid has not been studied for its role in nail plate synthesis¹⁸; however, given the role that ascorbic acid plays in a myriad of biologic processes, the deficiency associated with scurvy likely had a considerable systemic effect in our patient that halted nail plate synthesis and resulted in the concurrent presentation of Beau lines, onychomadesis, and retronychia.

Beau lines are palpable transverse depressions on the dorsal aspect of the nail plate that result from a temporary slowing of nail plate production by the proximal nail matrix. Onychomadesis is a separation of the proximal nail plate from the distal nail plate leading to shedding of the nail. It occurs due to a complete growth arrest in the nail matrix and is thought to be on a continuum with Beau lines. The etiologies of these 2 conditions overlap and include trauma, inflammatory diseases, systemic illnesses, hereditary conditions, and infections.^1-5 In almost all cases of both conditions, normal nail plate production ensues upon identification and removal of the inciting agent or recuperation from the causal illness.^3,4,6 Beau lines will move distally as the nail grows out and can be clipped. In onychomadesis, the affected nails will be shed with time. Resolution of these nail defects can be estimated from average nail growth rates (1 mm/mo for fingernails and 2–3 mm/mo for toenails).⁷

Retronychia is defined as a proximal ingrowing of the nail plate into the ventral surface of the proximal nail fold.^4,6 It is thought to occur via vertical progression of the nail plate into the proximal nail fold, repetitive nail matrix trauma, or shearing forces, resulting in inflammation that leads to nail plate stacking.^8,9 Although conservative treatment using topical corticosteroids may be attempted, proximal nail plate avulsion typically is required for treatment.¹⁰

Braswell et al¹ suggested a unifying hypothesis for a common pathophysiologic basis for these 3 conditions; that is, nail matrix injury results in slowing and/or cessation of nail plate production, followed by recommencement of nail plate production by the nail matrix after removal of the insult. We report a case of a patient presenting with concurrent Beau lines, onychomadesis, and retronychia following scurvy, thus supporting the hypothesis that these 3 nail conditions lie on a continuum.

Case Report

A 41-year-old woman with a history of thyroiditis, gastroesophageal reflux disease, endometriosis, osteoarthritis, gastric ulcer, pancreatitis, fatty liver, and polycystic ovarian syndrome presented with lines on the toenails and no growth of the right second toenail of several months’ duration. She denied any pain or prior trauma to the nails, participation in sports activities, or wearing tight or high-heeled shoes. She had presented 6 months prior for evaluation of perifollicular erythema on the posterior thighs, legs, and abdomen, as well as gingival bleeding.¹¹ At that time, one of the authors (S.R.L.) found that she was vitamin C deficient, and a diagnosis of scurvy was made. The rash and gingival bleeding resolved with vitamin C supplementation.¹¹

At the current presentation, physical examination revealed transverse grooves involving several fingernails but most evident on the left thumbnail (Figure, A). The grooves did not span the entire breadth of the nail, which was consistent with Beau lines. Several toenails had parallel transverse grooves spanning the entire width of the nail plate such that the proximal nail plate was discontinuous with the distal nail plate, which was consistent with onychomadesis (Figure, B). The right second toenail was yellow and thickened with layered nail plates, indicative of retronychia (Figure, B). Histopathology of a nail plate clipping from the right second toenail was negative for fungal hyphae, and a radiograph was negative for bony changes or exostosis.

Comment

The nail matrix is responsible for nail plate production, and the newly formed nail plate then moves outward over the nail bed. It is hypothesized that the pathophysiologic basis for Beau lines, onychomadesis, and retronychia lies on a continuum such that all 3 conditions are caused by an insult to the nail matrix that results in slowing and/or halting of nail plate growth. Beau lines result from slowing or disruption in cell growth from the nail matrix, whereas onychomadesis is associated with a complete halt in nail plate production.^1,3 In retronychia, the new nail growing from the matrix pushes the old one upward, interrupting the longitudinal growth of the nail and leading to nail plate stacking.¹⁰

Our patient presented with concurrent Beau lines, onychomadesis, and retronychia. Although Beau lines and onychomadesis have been reported together in some instances,^12-14 retronychia is not commonly reported with either of these conditions. The exact incidence of each condition has not been studied, but Beau lines are relatively common, onychomadesis is less common, and retronychia is seen infrequently; therefore, the concurrent presentation of these 3 conditions in the same patient is exceedingly rare. Thus, it was most likely that one etiology accounted for all 3 nail findings.

Because the patient had been diagnosed with scurvy 6 months prior to presentation, we hypothesized that the associated vitamin C deficiency caused a systemic insult to the nail matrix, which resulted in cessation of nail growth. The mechanism of nail matrix arrest in the setting of systemic disease is thought to be due to inhibition of cellular proliferation or a change in the quality of the newly manufactured nail plate, which becomes thinner and more dystrophic.¹⁵ Vitamin C (ascorbic acid) deficiency causes scurvy, which is characterized by cutaneous signs such as perifollicular hemorrhage and purpura, corkscrew hairs, bruising, gingivitis, arthralgia, and impaired wound healing.¹⁶ These clinical manifestations are due to impaired collagen synthesis and disordered connective tissue. Ascorbic acid also is involved in fatty acid transport, neurotransmitter synthesis, prostaglandin metabolism, and nitric oxide synthesis.¹⁷ Ascorbic acid has not been studied for its role in nail plate synthesis¹⁸; however, given the role that ascorbic acid plays in a myriad of biologic processes, the deficiency associated with scurvy likely had a considerable systemic effect in our patient that halted nail plate synthesis and resulted in the concurrent presentation of Beau lines, onychomadesis, and retronychia.

Practice Gap

Myxoid cysts are among the most common space-occupying lesions involving the nail unit. Their etiology has not been fully elucidated, but these cysts likely form due to leakage of synovial fluid following trauma or chronic wear and tear. They are highly associated with osteoarthritis and typically are found in close proximity to the distal interphalangeal joints.¹ Myxoid cysts often extend into the eponychium, where mechanical stress on the nail matrix may lead to nail dystrophy, most commonly resulting in a longitudinal groove in the nail plate (Figure, A). The presence of multiple myxoid cysts is not uncommon. Differentiation of this lesion from other nodules of the digits, including epidermoid cysts, acquired digital fibrokeratomas, and giant cell tendon sheath tumors often is challenging without a biopsy.

Technique

The normal nail unit transmits light to some extent, and masses may be identified by how easily they transmit light relative to the adjacent skin. Solid tumors of the nail unit, such as acquired digital fibrokeratomas and giant cell tendon sheath tumors, will not transmit light, while myxoid cysts transmit light easily. A dermatoscope can be used to project light from the dorsal digit through the nail unit. The area occupied by the myxoid cyst will appear bright compared to the surrounding skin (Figure, B). Drainage of the lesion using an 18-gauge needle yielded a clear jellylike fluid that was consistent with a myxoid cyst. This technique aids in localizing and characterizing the myxoid cyst for treatment or drainage. Physician assessment of transillumination has been shown to demonstrate clinical accuracy and high intraobserver reliability in differentiating between cystic and solid tumors.²

Practice Implications

Transillumination is a valuable technique that may aid dermatologists in both the diagnosis and subsequent treatment of myxoid cysts. Location is important to consider when choosing a treatment option. Although lower recurrence rates are achieved with nail surgery, permanent nail dystrophy is likely when cysts are in close proximity to the nail matrix.³ When multiple cysts are present, only the largest may be apparent. Transillumination can guide the physician in achieving more accurate and thorough drainage of the cyst contents, negating the need for more costly imaging modalities. Dermatologists may utilize transillumination as a rapid and economical diagnostic method for space-occupying lesions involving the nail unit.

Practice Gap

Myxoid cysts are among the most common space-occupying lesions involving the nail unit. Their etiology has not been fully elucidated, but these cysts likely form due to leakage of synovial fluid following trauma or chronic wear and tear. They are highly associated with osteoarthritis and typically are found in close proximity to the distal interphalangeal joints.¹ Myxoid cysts often extend into the eponychium, where mechanical stress on the nail matrix may lead to nail dystrophy, most commonly resulting in a longitudinal groove in the nail plate (Figure, A). The presence of multiple myxoid cysts is not uncommon. Differentiation of this lesion from other nodules of the digits, including epidermoid cysts, acquired digital fibrokeratomas, and giant cell tendon sheath tumors often is challenging without a biopsy.

Technique

The normal nail unit transmits light to some extent, and masses may be identified by how easily they transmit light relative to the adjacent skin. Solid tumors of the nail unit, such as acquired digital fibrokeratomas and giant cell tendon sheath tumors, will not transmit light, while myxoid cysts transmit light easily. A dermatoscope can be used to project light from the dorsal digit through the nail unit. The area occupied by the myxoid cyst will appear bright compared to the surrounding skin (Figure, B). Drainage of the lesion using an 18-gauge needle yielded a clear jellylike fluid that was consistent with a myxoid cyst. This technique aids in localizing and characterizing the myxoid cyst for treatment or drainage. Physician assessment of transillumination has been shown to demonstrate clinical accuracy and high intraobserver reliability in differentiating between cystic and solid tumors.²

Practice Implications

Transillumination is a valuable technique that may aid dermatologists in both the diagnosis and subsequent treatment of myxoid cysts. Location is important to consider when choosing a treatment option. Although lower recurrence rates are achieved with nail surgery, permanent nail dystrophy is likely when cysts are in close proximity to the nail matrix.³ When multiple cysts are present, only the largest may be apparent. Transillumination can guide the physician in achieving more accurate and thorough drainage of the cyst contents, negating the need for more costly imaging modalities. Dermatologists may utilize transillumination as a rapid and economical diagnostic method for space-occupying lesions involving the nail unit.

Practice Gap

Myxoid cysts are among the most common space-occupying lesions involving the nail unit. Their etiology has not been fully elucidated, but these cysts likely form due to leakage of synovial fluid following trauma or chronic wear and tear. They are highly associated with osteoarthritis and typically are found in close proximity to the distal interphalangeal joints.¹ Myxoid cysts often extend into the eponychium, where mechanical stress on the nail matrix may lead to nail dystrophy, most commonly resulting in a longitudinal groove in the nail plate (Figure, A). The presence of multiple myxoid cysts is not uncommon. Differentiation of this lesion from other nodules of the digits, including epidermoid cysts, acquired digital fibrokeratomas, and giant cell tendon sheath tumors often is challenging without a biopsy.

Technique

The normal nail unit transmits light to some extent, and masses may be identified by how easily they transmit light relative to the adjacent skin. Solid tumors of the nail unit, such as acquired digital fibrokeratomas and giant cell tendon sheath tumors, will not transmit light, while myxoid cysts transmit light easily. A dermatoscope can be used to project light from the dorsal digit through the nail unit. The area occupied by the myxoid cyst will appear bright compared to the surrounding skin (Figure, B). Drainage of the lesion using an 18-gauge needle yielded a clear jellylike fluid that was consistent with a myxoid cyst. This technique aids in localizing and characterizing the myxoid cyst for treatment or drainage. Physician assessment of transillumination has been shown to demonstrate clinical accuracy and high intraobserver reliability in differentiating between cystic and solid tumors.²

Practice Implications

Transillumination is a valuable technique that may aid dermatologists in both the diagnosis and subsequent treatment of myxoid cysts. Location is important to consider when choosing a treatment option. Although lower recurrence rates are achieved with nail surgery, permanent nail dystrophy is likely when cysts are in close proximity to the nail matrix.³ When multiple cysts are present, only the largest may be apparent. Transillumination can guide the physician in achieving more accurate and thorough drainage of the cyst contents, negating the need for more costly imaging modalities. Dermatologists may utilize transillumination as a rapid and economical diagnostic method for space-occupying lesions involving the nail unit.

To the Editor:

We read with great interest the recent Cutis article by Golda et al,¹ “Intraoperative Electrosurgical Smoke During Outpatient Surgery: A Survey of Dermatologic Surgeon and Staff Preferences.” We applaud the growing interest in the topic of dermatologist safety, as there are currently no established guidelines for precautions while performing surgical procedures. In 2018 we conducted a comprehensive review² to characterize the specific risks, hazard reduction strategies available, and current use of surgical smoke safety techniques during surgery among dermatologists, and ultimately recommend guidance based on the current available evidence. To conduct this review, we collected data from 45 manuscripts in the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature. Herein, we summarize key findings.²

Dermatologic surgeons, residents, staff, and patients are exposed to many infectious, inhalational, chemical, and mutagenic hazards when performing procedures that liberate smoke and plume. These risks are commonplace; however, they are particularly notable during ablative laser and laser hair removal procedures, which produce a heavy plume (averaging >100,000 particles/cm³). Brief periods of heavy plume exposure also are commonplace during electrosurgery.

Infectious particles in surgical plume have been extensively studied, and viral transmission has been demonstrated in animal studies. Human papillomavirus transmission appears to be the most prevalent risk. Surgical smoke has been shown to cause acute and chronic inhalational injury in rat and sheep studies.^3-6

Additionally, chemicals with carcinogenic potential are present in surgical smoke and have been described.^7,8 Chemicals in the greatest quantity include hydrocarbons, nitriles, fatty acids, and phenols. Although there have been no human studies on smoke carcinogenesis to date, surgical smoke has been shown to have carcinogenic properties in vitro.

Given these risks—both evidence based and theoretical—we believe that diligent hazard reduction strategies should be employed whenever possible. Surgical masks and high-efficiency particulate air respirators, such as N95 respirator masks, have been well studied and do provide smoke protection. High-efficiency particulate air masks can be worn when possible, especially during procedures that produce heavy plume, though surgical masks are capable of filtering most of the noxious chemicals in surgical smoke. It should be noted that proper fit with minimal air leak is the most important aspect of overall performance.

Smoke evacuators provide another level of protection. The physician should consider the evacuator’s filtration efficiency, capture velocity, and suction strength when evaluating overall performance. Furthermore, the smoke collection tip should be within 2 in of the surgical field to maximize efficacy. Maintenance for smoke evacuation systems should include regular (as defined by manufacturer instructions) flushing of the smoke evacuator lines.

Despite the risks of surgical smoke and the available options of minimizing these risks, the hazards of surgical smoke and the importance of protection are likely underemphasized. Many dermatologic surgeons do not use surgical masks or smoke evacuators in routine practice, according to several survey studies.^9-11

It is important for the dermatologic community to consider effective ways of spreading awareness. We propose that surgical smoke safety be taught early in residency training. Additionally, smoke safety can be implemented into certification examinations. Access to masks and smoke evacuation devices are an important part of dermatology training. Accreditation Council for Graduate Medical Education funds should be appropriated to provide for such resources.

Finally, and perhaps most importantly, continued awareness should be established in the dermatology community via standardized guidelines and periodic updates in the dermatology literature and lectures at local and national conferences. Not until these strategies are implemented will surgical smoke protection be viewed as a necessary and important component of routine practice when performing dermatologic surgical procedures.

To the Editor:

We read with great interest the recent Cutis article by Golda et al,¹ “Intraoperative Electrosurgical Smoke During Outpatient Surgery: A Survey of Dermatologic Surgeon and Staff Preferences.” We applaud the growing interest in the topic of dermatologist safety, as there are currently no established guidelines for precautions while performing surgical procedures. In 2018 we conducted a comprehensive review² to characterize the specific risks, hazard reduction strategies available, and current use of surgical smoke safety techniques during surgery among dermatologists, and ultimately recommend guidance based on the current available evidence. To conduct this review, we collected data from 45 manuscripts in the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature. Herein, we summarize key findings.²

Dermatologic surgeons, residents, staff, and patients are exposed to many infectious, inhalational, chemical, and mutagenic hazards when performing procedures that liberate smoke and plume. These risks are commonplace; however, they are particularly notable during ablative laser and laser hair removal procedures, which produce a heavy plume (averaging >100,000 particles/cm³). Brief periods of heavy plume exposure also are commonplace during electrosurgery.

Infectious particles in surgical plume have been extensively studied, and viral transmission has been demonstrated in animal studies. Human papillomavirus transmission appears to be the most prevalent risk. Surgical smoke has been shown to cause acute and chronic inhalational injury in rat and sheep studies.^3-6

Additionally, chemicals with carcinogenic potential are present in surgical smoke and have been described.^7,8 Chemicals in the greatest quantity include hydrocarbons, nitriles, fatty acids, and phenols. Although there have been no human studies on smoke carcinogenesis to date, surgical smoke has been shown to have carcinogenic properties in vitro.

Given these risks—both evidence based and theoretical—we believe that diligent hazard reduction strategies should be employed whenever possible. Surgical masks and high-efficiency particulate air respirators, such as N95 respirator masks, have been well studied and do provide smoke protection. High-efficiency particulate air masks can be worn when possible, especially during procedures that produce heavy plume, though surgical masks are capable of filtering most of the noxious chemicals in surgical smoke. It should be noted that proper fit with minimal air leak is the most important aspect of overall performance.

Smoke evacuators provide another level of protection. The physician should consider the evacuator’s filtration efficiency, capture velocity, and suction strength when evaluating overall performance. Furthermore, the smoke collection tip should be within 2 in of the surgical field to maximize efficacy. Maintenance for smoke evacuation systems should include regular (as defined by manufacturer instructions) flushing of the smoke evacuator lines.

Despite the risks of surgical smoke and the available options of minimizing these risks, the hazards of surgical smoke and the importance of protection are likely underemphasized. Many dermatologic surgeons do not use surgical masks or smoke evacuators in routine practice, according to several survey studies.^9-11

It is important for the dermatologic community to consider effective ways of spreading awareness. We propose that surgical smoke safety be taught early in residency training. Additionally, smoke safety can be implemented into certification examinations. Access to masks and smoke evacuation devices are an important part of dermatology training. Accreditation Council for Graduate Medical Education funds should be appropriated to provide for such resources.

Finally, and perhaps most importantly, continued awareness should be established in the dermatology community via standardized guidelines and periodic updates in the dermatology literature and lectures at local and national conferences. Not until these strategies are implemented will surgical smoke protection be viewed as a necessary and important component of routine practice when performing dermatologic surgical procedures.

To the Editor:

We read with great interest the recent Cutis article by Golda et al,¹ “Intraoperative Electrosurgical Smoke During Outpatient Surgery: A Survey of Dermatologic Surgeon and Staff Preferences.” We applaud the growing interest in the topic of dermatologist safety, as there are currently no established guidelines for precautions while performing surgical procedures. In 2018 we conducted a comprehensive review² to characterize the specific risks, hazard reduction strategies available, and current use of surgical smoke safety techniques during surgery among dermatologists, and ultimately recommend guidance based on the current available evidence. To conduct this review, we collected data from 45 manuscripts in the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature. Herein, we summarize key findings.²

Dermatologic surgeons, residents, staff, and patients are exposed to many infectious, inhalational, chemical, and mutagenic hazards when performing procedures that liberate smoke and plume. These risks are commonplace; however, they are particularly notable during ablative laser and laser hair removal procedures, which produce a heavy plume (averaging >100,000 particles/cm³). Brief periods of heavy plume exposure also are commonplace during electrosurgery.

Infectious particles in surgical plume have been extensively studied, and viral transmission has been demonstrated in animal studies. Human papillomavirus transmission appears to be the most prevalent risk. Surgical smoke has been shown to cause acute and chronic inhalational injury in rat and sheep studies.^3-6

Additionally, chemicals with carcinogenic potential are present in surgical smoke and have been described.^7,8 Chemicals in the greatest quantity include hydrocarbons, nitriles, fatty acids, and phenols. Although there have been no human studies on smoke carcinogenesis to date, surgical smoke has been shown to have carcinogenic properties in vitro.

Given these risks—both evidence based and theoretical—we believe that diligent hazard reduction strategies should be employed whenever possible. Surgical masks and high-efficiency particulate air respirators, such as N95 respirator masks, have been well studied and do provide smoke protection. High-efficiency particulate air masks can be worn when possible, especially during procedures that produce heavy plume, though surgical masks are capable of filtering most of the noxious chemicals in surgical smoke. It should be noted that proper fit with minimal air leak is the most important aspect of overall performance.

Smoke evacuators provide another level of protection. The physician should consider the evacuator’s filtration efficiency, capture velocity, and suction strength when evaluating overall performance. Furthermore, the smoke collection tip should be within 2 in of the surgical field to maximize efficacy. Maintenance for smoke evacuation systems should include regular (as defined by manufacturer instructions) flushing of the smoke evacuator lines.

Despite the risks of surgical smoke and the available options of minimizing these risks, the hazards of surgical smoke and the importance of protection are likely underemphasized. Many dermatologic surgeons do not use surgical masks or smoke evacuators in routine practice, according to several survey studies.^9-11

It is important for the dermatologic community to consider effective ways of spreading awareness. We propose that surgical smoke safety be taught early in residency training. Additionally, smoke safety can be implemented into certification examinations. Access to masks and smoke evacuation devices are an important part of dermatology training. Accreditation Council for Graduate Medical Education funds should be appropriated to provide for such resources.

Finally, and perhaps most importantly, continued awareness should be established in the dermatology community via standardized guidelines and periodic updates in the dermatology literature and lectures at local and national conferences. Not until these strategies are implemented will surgical smoke protection be viewed as a necessary and important component of routine practice when performing dermatologic surgical procedures.