Green nail syndrome | |
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Other names | Chloronychia, Goldman–Fox syndrome [1] [2] |
Chloronychia affecting the nail of the ring finger | |
Specialty | Dermatology |
Green nail syndrome is an infection that can develop in individuals whose hands are frequently submerged in water resulting in discolouration of the nails from shades of green to black. [3] [4] It may also occur as transverse green stripes that are ascribed to intermittent episodes of infection. [3] It is usually caused by the bacteria Pseudomonas aeruginosa [5] and is linked to hands being constantly moist or exposed to chemicals, or in individuals who have damaged or traumatised nails. [6] There are several activities and nail injuries or conditions that are linked to higher risk of contracting the condition.
Green nail syndrome (chloronychia or Goldman-Fox syndrome [7] ) is characterised by discolouration of the infected nail, inflammation of the skin around the nail known as paronychia, and an odour resembling fruit. [3] The colour may range from light or blueish green or yellow-green to darker green or black. [8] [3] Nails may be separated from the nail bed (onycholysis) [3] and may have green stripes from repeated infections. [3] Chronic fungal infection (onychomycosis) may also be present. [4]
Green nail syndrome is caused when the nail is exposed to a bacterial organism, which leads to opportunistic infection. [9] Pseudomonas aeruginosa, the most common cause but not the only one, [10] is frequently found in nature including in water sources, humans, animals and soil. [9] [10] These bacteria do not normally survive on dry, healthy skin, but can thrive in moist conditions. [9] The seal between the nail and finger acts as a physical barrier to prevent infection, however hyper-hydration or destruction of the epidermis can impair the barrier, allowing the bacteria to colonise.[ medical citation needed ]The nail turns green due to the bacteria secreting pigments such as pyocyanin [3] [4] and pyoverdin. [9]
Green nail syndrome occurs rarely in healthy individuals, but can occur in the immunocompromised or those whose hands are frequently immersed in water or who have other nail problems. [5] The elderly and people who have had trauma to a finger or nail are at greater risk of contracting green nail syndrome. [1]
Green nail syndrome has been linked to manicures, [11] heat, dermatitis, ulcerations, occlusions and excess sweating.[ medical citation needed ]Higher risk of contracting the infection is also linked to soccer players and military personnel due to the prolonged periods of time in which they exercise while wear tight fitting shoes [12] as well as immunosuppressed persons and those with a weakened epidermis barrier.
Pseudomonas can be transferred among clients in a nail salon if appropriate hygiene standards are not practiced, allowing transfer of the bacteria to clients. [13] Artificial nails may be a contributing factor, and their use can result in diagnostic delay. [8]
A man working in a job where he was regularly mixing chemicals developed green nails secondary to exposure to chemicals; he mostly wore latex gloves, but sometimes did not, and the type of gloves he used was inadequate, resulting in a constantly moist environment. [14]
Cloronychia may be transferred to patients in clinics by medical practitioners, even when they are wearing gloves. [6]
Diagnosis can typically be made from a physical examination of the nail, although cultures are sometimes needed. [8] Nail scrapings [15] can be performed to rule out fungal infections. [4]
Green nails may also be seen with Proteus mirabilis infection, in psoriasis, or because of use of triphenylmethane dyes [3] or other stains and lacquers or chemical solutions. [8] [4] Melanoma is an infrequent differential diagnosis, which must be ruled out in hard-to-treat cases. [4] Other differential diagnoses include hematoma and fungal infections (onychomycosis). [8]
Preventative measures should be implemented by those who are most at risk of contracting green nail syndrome due to their predisposition or lifestyle and workplace choices. Wearing waterproof gloves or rubber boots can be effective in preventing prolonged exposure of the nails to water. Avoiding trauma that could lead to the destruction of the epidermis seal is on the nails is a priority in preventing green nail syndrome recurrences.[ medical citation needed ]
As of 2020, there have not been controlled, blinded studies on the treatment of green nail syndrome [16] and there are no treatment guidelines as of 2021. [8] Keeping the nails dry and avoiding excessive immersion of the nails are key. [11] In some cases, surgical removal of the infected nail may be required, [16] as a last choice. [8] The patient is advised to avoid further trauma to the infected nail regardless of the treatment they received. [12]
Oral antibiotics are rarely necessary, helpful [4] or recommended by all practitioners. [3] Moderate cases of green nail syndrome may be prescribed topical antibiotics (silver sulfadiazine, gentamicin, ciprofloxacin, bacitracin and polymyxin B). [16] Oral antibiotics are sometimes used if other therapies fail. [16] Tobramycin eye drops are sometimes used. [16]
The least invasive treatment includes soaking the nail in alcohol and regularly trimming the nail back,[ medical citation needed ] to dry out the area and prevent bacterial colonization. [15] Some at-home treatments include soaking the nails in vinegar (diluted with water 1:1) or a chlorine bleach solution (diluted with water 1:4) at regular intervals. [4]
Goldman–Fox syndrome was first described in 1944 by Leon Goldman, a dermatology professor at the University of Cincinnati, and Harry Fox. [2] [7] [17]
Waterhouse–Friderichsen syndrome (WFS) is defined as adrenal gland failure due to bleeding into the adrenal glands, commonly caused by severe bacterial infection. Typically, it is caused by Neisseria meningitidis.
A blister is a small pocket of body fluid within the upper layers of the skin, usually caused by forceful rubbing (friction), burning, freezing, chemical exposure or infection. Most blisters are filled with a clear fluid, either serum or plasma. However, blisters can be filled with blood or with pus.
A nail disease or onychosis is a disease or deformity of the nail. Although the nail is a structure produced by the skin and is a skin appendage, nail diseases have a distinct classification as they have their own signs and symptoms which may relate to other medical conditions. Some nail conditions that show signs of infection or inflammation may require medical assistance.
Aztreonam, sold under the brand name Azactam among others, is an antibiotic used primarily to treat infections caused by gram-negative bacteria such as Pseudomonas aeruginosa. This may include bone infections, endometritis, intra abdominal infections, pneumonia, urinary tract infections, and sepsis. It is given by intravenous or intramuscular injection or by inhalation.
Dermatophyte is a common label for a group of fungus of Arthrodermataceae that commonly causes skin disease in animals and humans. Traditionally, these anamorphic mold genera are: Microsporum, Epidermophyton and Trichophyton. There are about 40 species in these three genera. Species capable of reproducing sexually belong in the teleomorphic genus Arthroderma, of the Ascomycota. As of 2019 a total of nine genera are identified and new phylogenetic taxonomy has been proposed.
Ceftazidime, sold under the brand name Fortaz among others, is a third-generation cephalosporin antibiotic useful for the treatment of a number of bacterial infections. Specifically it is used for joint infections, meningitis, pneumonia, sepsis, urinary tract infections, malignant otitis externa, Pseudomonas aeruginosa infection, and vibrio infection. It is given by injection into a vein, muscle, or eye.
Paronychia is an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacterium Staphylococcus aureus, or gradually when it is commonly caused by the fungus Candida albicans. The term is from Greek: παρωνυχία from para 'around', onyx 'nail', and the abstract noun suffix -ia.
Dermatophytosis, also known as ringworm, is a fungal infection of the skin. Typically it results in a red, itchy, scaly, circular rash. Hair loss may occur in the area affected. Symptoms begin four to fourteen days after exposure. Multiple areas can be affected at a given time.
Onychomycosis, also known as tinea unguium, is a fungal infection of the nail. Symptoms may include white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed. Fingernails may be affected, but it is more common for toenails. Complications may include cellulitis of the lower leg. A number of different types of fungus can cause onychomycosis, including dermatophytes and Fusarium. Risk factors include athlete's foot, other nail diseases, exposure to someone with the condition, peripheral vascular disease, and poor immune function. The diagnosis is generally suspected based on the appearance and confirmed by laboratory testing.
Pseudomonas aeruginosa is a common encapsulated, Gram-negative, aerobic–facultatively anaerobic, rod-shaped bacterium that can cause disease in plants and animals, including humans. A species of considerable medical importance, P. aeruginosa is a multidrug resistant pathogen recognized for its ubiquity, its intrinsically advanced antibiotic resistance mechanisms, and its association with serious illnesses – hospital-acquired infections such as ventilator-associated pneumonia and various sepsis syndromes. P. aeruginosa is able to selectively inhibit various antibiotics from penetrating its outer membrane - and has high resistance to several antibiotics, according to the World Health Organization P. aeruginosa poses one of the greatest threats to humans in terms of antibiotic resistance.
Carbapenems are a class of very effective antibiotic agents most commonly used for treatment of severe bacterial infections. This class of antibiotics is usually reserved for known or suspected multidrug-resistant (MDR) bacterial infections. Similar to penicillins and cephalosporins, carbapenems are members of the beta-lactam antibiotics drug class, which kill bacteria by binding to penicillin-binding proteins, thus inhibiting bacterial cell wall synthesis. However, these agents individually exhibit a broader spectrum of activity compared to most cephalosporins and penicillins. Furthermore, carbapenems are typically unaffected by emerging antibiotic resistance, even to other beta-lactams.
A skin infection is an infection of the skin in humans and other animals, that can also affect the associated soft tissues such as loose connective tissue and mucous membranes. They comprise a category of infections termed skin and skin structure infections (SSSIs), or skin and soft tissue infections (SSTIs), and acute bacterial SSSIs (ABSSSIs). They are distinguished from dermatitis, although skin infections can result in skin inflammation.
Hospital-acquired pneumonia (HAP) or nosocomial pneumonia refers to any pneumonia contracted by a patient in a hospital at least 48–72 hours after being admitted. It is thus distinguished from community-acquired pneumonia. It is usually caused by a bacterial infection, rather than a virus.
Clobetasone (INN) is a corticosteroid used in dermatology, for treating such skin inflammation as seen in eczema, psoriasis and other forms of dermatitis, and ophthalmology. Topical clobetasone butyrate has shown minimal suppression of the hypothalamic–pituitary–adrenal axis.
Amorolfine, is a morpholine antifungal drug that inhibits Δ14-sterol reductase and cholestenol Δ-isomerase, which depletes ergosterol and causes ignosterol to accumulate in the fungal cytoplasmic cell membranes. Marketed as Curanail, Loceryl, Locetar, and Odenil, amorolfine is commonly available in the form of a nail lacquer, containing 5% amorolfine hydrochloride as the active ingredient. It is used to treat onychomycosis. Amorolfine 5% nail lacquer in once-weekly or twice-weekly applications was shown in two decades-old studies to be between 60% and 71% effective in treating toenail onychomycosis; complete cure rates three months after stopping treatment were 38% and 46%. However, full experimental details of these trials were not available, and since they were first reported in 1992 there have been no subsequent trials.
Pseudomonas infection refers to a disease caused by one of the species of the genus Pseudomonas.
Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule, pimple or spot.
Bullous impetigo is a bacterial skin infection caused by Staphylococcus aureus that results in the formation of large blisters called bullae, usually in areas with skin folds like the armpit, groin, between the fingers or toes, beneath the breast, and between the buttocks. It accounts for 30% of cases of impetigo, the other 70% being non-bullous impetigo.
Multidrug resistant Gram-negative bacteria are a type of Gram-negative bacteria with resistance to multiple antibiotics. They can cause bacteria infections that pose a serious and rapidly emerging threat for hospitalized patients and especially patients in intensive care units. Infections caused by MDR strains are correlated with increased morbidity, mortality, and prolonged hospitalization. Thus, not only do these bacteria pose a threat to global public health, but also create a significant burden to healthcare systems.