A long life is a cherished desire of every man, but all are not destined to enjoy it. The elderly are defined as those who are 60 years of age and above. The population of the elderly in India is steadily growing and the number is already quite large. As per SRS estimation, in 2003, the elderly formed 7.2% of the total population of India.
No cutaneous examination is complete without a careful evaluation of the nails of the patient. Nail changes associated with ageing are common in the elderly and include changes in color, contour, growth, surface, thickness, and histology.
The calcium content of the ageing nail is increased and the iron content is decreased. Histologically, the keratinocytes of the nail plate are increased in size and have an increased number of ‘pertinax bodies’ (remnant of keratinocyte nucleus). The nail bed dermis also shows thickening of the blood vessels and elastic tissue, especially beneath the pink part of the nail. Nail growth decreases by approximately 0.5% per year between the ages of 20 and 100 years.
There have not been many studies in our country on nail changes in ageing and the prevalence of nail disorders in the elderly. Hence, we have undertaken this study.
Elderly patients of 60 years and above were included in our study. Every second elderly patient attending the OPD each day was included in the study, irrespective of the presenting symptoms. A total of 100 patients were enrolled by this method that was designed to eliminate observer bias in the study. A detailed history of each patient was taken, after which we conducted a thorough general examination and an examination of the nail and hair. In all the suspected cases of onychomycosis we examined a KOH preparation of nail clipping microscopically to detect fungal infection.
The following Table shows the age- and sex-wise breakup of the patients enrolled for the study [Table 1].
Age and sex distribution of subjects
The youngest elderly patient was 60 years and the oldest was 101 years old. Six percent of the subjects reported that they had the habit of occasional nail biting.
The majority of the patients were not conscious of their nail changes and nail diseases. However, in 14 cases (14.28%) it was the presenting complaint.
General examination of the patients showed that 44 had mild conjunctival pallor, suggesting the presence of mild anemia. It was also seen that they suffered from various systemic diseases like hypertension (19%), diabetes mellitus (5%), COPD and bronchial asthma (5%), ischemic heart disease (4%), arthritis (2%), prostatic hypertrophy (1%), and parkinsonism (1%).
Out of 100 patients, 98 showed at least one change in the nails due to ageing. Two patients, both incidentally female, did not show any change due to ageing.
With regard to age-related color changes of nail plate, a pale, dull, and lustreless nail plate was seen in 73% of patients, opacity in 8%, and grey color in 6%.
As the age increases, lunular visibility decreases. In 31 cases, the lunula was visible. Among those who had visible lunula, 23 were from the age-group of 60–70 years. In these patients lunular visibility was maximum (100%) in the LF1 (first left finger, i.e., the left thumb) and RF1 (first right finger, i.e., right thumb), followed by 67.8% and 64.5% lunular visibility for the RT1 (right first toe) and RT2 (right second toe), respectively. Lunular visibility was very low to 0% in the other fingers and toes.
Among the age-related changes in the nail surface, prominent longitudinal ridges were the commonest (in 85%), followed by rough nails in 33% of the patients, transverse ridges in 23%, and lamellar split in 15% of cases.
Brittleness of the nail is a common condition related to aging. Twenty-six (40%) males and 8 (26%) females showed brittle nails. The prevalence of brittle nail was higher in the toe nails in both sexes. Among males, 25 had brittleness of toe nails, 5 had brittleness of finger nails, and 4 had brittleness of both finger and toe nails. Among females, 8 had brittle toenails, 2 had brittle fingernails, and 2 had brittleness of both finger and toe nails.
Onychauxis or thickening of the nail plate, which is associated with ageing, was noticed in 23% of the subjects, with the prevalence being 10% in the left great toe and 13% in the right great toe, followed by 7% in right fifth toe and 4% in left fourth toe.
With regard to changes in nail contour, increased transverse curvature was seen in five cases, pincer nail [Figure 1] in two, and platonychia in one case.
Table 2shows the prevalence of nail disorders in the elderly. Out of 33 cases of acquired disorders, the majority were infective disease. Onychomycosis was seen in 16%, followed by chronic paronychia [Figure 2] in 9%. A single disorder was seen in 31%, two disorders were seen in 4%, and three disorders were seen in 1% of the patients.
Prevalence of nail disorders
Chronic paronychia with periungual warts
The prevalence of onychomycosis was 22% in women and 12% in men. The commonest change in onychomycosis was loss of lustre, subungual hyperkerotosis, onycholysis, brittleness, and color change with blackish brownish or yellowish discoloration.
The finger nails were involved in 10 patients and the toe nails in 12 patients.
Out of the nine patients suffering from chronic paronychia, five were male. Of them, three were retired, one was a farmer, and another jobless. Of the four female patients, three were housewives and one a maidservant. The right thumb, index, and ring fingers were affected in four cases each; the left thumb and right middle finger in three cases; the left index, middle, ring, and little fingers in two cases; and the right little finger and left toe in two cases each. Hence, overall, the right hand was found to be affected more commonly. Common changes seen in chronic paronychia were loss of cuticle and nail fold erythema and edema. Common nail plate changes were transverse furrows, loss of lustre, and thickening.
Traumatic nail disorders were the third most common disorder seen in the study, with eight patients affected. Subungual hematoma was seen in three cases, nail loss in two, and onycholysis in two. One case of splinter haemorrhage was also seen.
In our study we found that senile changes in elderly could be classified under four headings: (1) change in color, with emphasis on lunular color change; (2) change in contour of nail; (3) change in the surface of nail and brittleness of nails; and (4) gross change in thickness of nail, with presence of onychauxis.
The commonest change seen in the ageing nail was a pale, dull and lustreless appearance, which was apparent in 73% of the patients. The color of the ageing nail varied from yellow to grey and there was a dull opaque appearance. Other authors have reported that the senile nail may appear pale, dull and opaque, with color varying from white or yellow to brown to grey.
Though the lunula is often not visible in all fingers and toes, it is most consistently observed on the thumb, in the index finger, and the great toes. The same was true in our study also. The lunular size decreased with age and this has been previously noted as an ageing-related nail change in elderly persons. In our study, we found that the lunula was not visible in 69 cases and the visibility of the lunula decreased consistently with ageing.
Changes on the surface of the nail due to ageing can be seen as increased longitudinal furrowing or ridges and increased friability and fissuring. Ageing is the commonest cause of onychorrhexis or superficial longitudinal ridges. Transverse furrows/ridges are also found very frequently. The nails may be rough (trachyonychia, with lamellar splitting and fissuring). In our study we found prominent/increased longitudinal ridges in 85% of cases, with no significant difference between the percentages of finger and toe nails involved. Transverse ridges/furrows (22%) were seen in the toe nails in all 22 patients (mainly in the great toe nails), while it was seen in the finger nails in 2 cases. Rough nail (33%) was also seen mostly in the toes.
Repeated cycles of hydration and dehydration, as occurs during excessive domestic wet work or with overuse of dehydrating agents, nail enamel, nail enamel removers, or cuticle removers may precipitate brittle nails. Brittle nail is a common finding in the elderly. Similar observations have been made by Lubach et al. In their study on elderly patients of 60 years and above, the incidence of brittle nails was 31% in males and 36% in females. The first three fingers of the dominant hand are particularly susceptible to brittle nails. In our study, we found the prevalence of brittle nails to be 34%. The incidence of brittle nails is higher in the toe nails in our study because our study population mainly comprised poor patients who walk barefoot or use ill-fitting shoes and sandals. Constant low-grade trauma hastens the onset of brittle nail changes seen in elderly patients.
Senile nails may have an increased transverse curvature and a decreased longitudinal curvature. Flattening of the nail plate (platonchia), spooning (koilonychia), and pincer nail deformity are found more frequently in the elderly. In our study, we observed increased transverse curvature in five cases. We also found two cases of pincer nail and one case of platyonychia. No case of koilonychia was seen in our study.
The prevalence of onychomycosis increases with age and reaches nearly 20% in patients over 60 years. In our study we found the prevalence of onychomycosis to be 15%. Among the elderly, onychomycosis is more common in men than in women. In our study we found that the prevalence of onychomycosis in women was 22%, whereas in men it was 12%. The most common type of onychomycosis observed in our study was distal and lateral subungual onychomycosis; this has also been reported earlier. Chronic paronychia (9%) was also not uncommon in the present study. The right hand, being the working hand of the majority, is found to be predominantly affected. Most of the patients in our study were from the poorer section of the society. Many of them walked barefoot most of the time. Due to their unsanitary environment, their feet are usually exposed to dirty and wet conditions. The above factors probably induced and hastened the onset of brittle nails in our study group. The occupation of many patients (as well as household work, especially in women) makes their hands and feet vulnerable to repeated minor trauma and exposure to water, chemicals and irritants for relatively long periods. These factors may have contributed to the ageing-related changes in our study group, besides contributing to onychomycosis and paronychia.
In our study we found six cases of psoriasis, out of which four presented with nail changes. The prevalence of nail involvement in psoriasis was thus 67%. Nail involvement is common in psoriasis and has been reported in between 50% and 56% of patients. It is estimated that over their lifetime 80%–90% of patients with psoriasis will suffer from nail disease. Pitting was the most common finding seen in all the four cases in our study, consistent with the descriptions by others. Pitting was more common in the finger nails than on the toe nails and were scattered rather than forming a regular pattern. Other common findings were subungual keratin deposits and onycholysis. Yellowish discoloration and loss of texture were also common. Though loss of cuticle has been a common finding reported by some workers it was not found in the present study.
As socioeconomic conditions improve and awareness increases, more and more geriatric patients will visit dermatologists with problems of their nails. Dermatologists will have to be prepared to handle such common geriatric problems in an organ that is part and parcel of their discipline.
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Approximately 350,000 people are employed in nail salons and other personal care services in the United States according to industry estimates (Nails Magazine, 2008–2009). These estimates indicate the workforce is largely female (96%) with the industry employing a large number of minority workers (63%). Nail salon employees are potentially exposed to dozens of chemicals including acrylates, solvents, and biocides as dusts or vapors. A small but growing number of studies have examined possible links between nail technicians’ work and health outcomes, such as respiratory, neurological, and musculoskeletal effects, as well as other health conditions. Much of the NIOSH-sponsored research to-date has focused on the respiratory system. Concerns about job-related health effects associated with chemicals routinely used by nail technicians drew new attention on May 11, 2015, when Governor Andrew M. Cuomo of New York announced a new initiative to “prevent unlawful practices and unsafe working conditions” in New York nail salons, following the publication of a two-part investigative series in the New York Times.
Nail technicians perform manicures and may also perform pedicures. Manicures are performed over a workstation—or “nail table”—with the client’s hands resting on the table as they work. The nail table is, therefore, directly below the nail technicians’ breathing zone. Downdraft vented nail tables and portable source capture systems that place local exhaust ventilation close to the work area provide the means to vent (remove) potential dust or chemicals away from the breathing zone. Thus, theoretically, potential contaminants may be removed before they cross the breathing zone and are inhaled. Good general room ventilation is also important. There is some overlap in nail products and processes for manicures and pedicures. Exposures may differ, though, as pedicures involve processes such as soaking feet, filing calluses, and the use of pedicure work stations, but do not typically involve artificial nail application.
The NIOSH publication entitled Controlling Chemical Hazards During the Application of Artificial Fingernails (NIOSH Publication No. 99-112) describes simple measures to reduce exposures during artificial nail application, such as keeping dispensers closed and wearing long sleeves and gloves to protect skin from potential irritants and sensitizers. Information is also provided on engineering controls, such as how to build a downdraft vented nail table that vents to the outdoors, plus references to other sources of information.
View the Spanish version of this report.
NIOSH Report:An Evaluation of Local Exhaust Ventilation Systems for Controlling Hazardous Exposures in Nail Salons
EPHB Report No. 005-164
The National Institute for Occupational Safety and Health (NIOSH) conducted a research project to examine the effectiveness of different portable source capture ventilation systems (SCVS) units with the potential for use in nail salons. Units received for evaluation in response to a Federal Register Notice featured local exhaust recirculation. With local exhaust recirculation, contaminated air is drawn through a filter and then vented it back into the room (for the NIOSH evaluation, however, air was vented into an exhaust system). The air intakes on these SCVS units could also be positioned so that contaminated air could be drawn into the unit before it crosses the breathing zone of the face. Airflow and capture characteristics of the units as well as the noise levels around them were evaluated.
NIOSHTIC-2 search results on manicurists and nail tables
NIOSHTIC-2 is a searchable bibliographic database of occupational safety and health publications, documents, grant reports, and journal articles based on research supported in whole or in part by NIOSH.
Journal Articles and Abstracts Published by NIOSH Authors
A pilot respiratory health assessment of nail technicians: symptoms, lung function, and airway inflammation
Am J Ind Med. 2009 Nov;52(11):868-75.
A pilot respiratory health assessment of nail technicians and a comparison group was conducted. Lung function values and symptoms were presented by group. Among the nail technician group, relationships between respiratory measures (lung function and nitric oxide) and some exposure measures were seen, suggesting a need for further study.
Urinary phthalate metabolite concentrations among workers in selected industries: a pilot biomonitoring study
Ann Occup Hyg. 2009 Jan;53(1):1-17.
Workers from manufacturing companies and nail-only (manicure) salons that used phthalates or phthalate-containing materials were recruited into the study. Manicure, pedicure and artificial nail services were provided at nail-only salons where di-n-butyl phthalate (DBP) was confirmed in polishes, topcoats and basecoats used by the study participants. Concentrations of 10 phthalate metabolites were measured in workers’ urine samples. Occupational exposure to DBP was most evident in rubber gasket, phthalate (raw material) and rubber hose manufacturing, with DBP metabolite concentrations exceeding general population levels by 26-, 25- and 10-fold, respectively, whereas DBP exposure in nail-only salons (manicurists) was 2-fold higher than in the general population.
Risk factors for asthma among cosmetology professionals in Colorado
J Occup Environ Med. 2006 Oct;48(10):1062-9.
A study was conducted of the prevalence, work-attributable risk, and tasks associated with asthma in a random sample of cosmeticians, manicurists, barbers, and cosmetologists holding licenses in Colorado. Application of artificial nails, hairstyling and shaving and honing were significantly associated with asthma arising in the course of employment.
Hazards of Ethyl Methacrylate [NIOSHTIC-2 abstract]
Am J Contact Dermat. 2000 Jun;11(2):119-20.
Letter to the editor with reference to NIOSH Health Report No. ECTB 171-05v, “Controlling Chemical Hazards in the Nail Salon Industry.” Contains a reply to commentary regarding the description of hazards of ethyl methacrylate in the NIOSH report.
A new manicure table for applying artificial fingernails [NIOSHTIC-2 abstract]
Appl Occup Environ Hyg. 2000 Jan;15(1):1-4.
A multi-station downdraft nail table was developed by NIOSH for workplaces where several clients are served at once. A schematic of the table, which vents to the outdoors, was shown and other measures to reduce exposures are described. The table was evaluated and shown to reduce levels of ethyl methacrylate in personal breathing zones.
Control of ethyl methacrylate exposures during the application of artificial fingernails
Am Ind Hyg Assoc J. 1997 Mar;58(3):214-8.
A commercially available recirculating downdraft nail table with charcoal filters was purchased and evaluated. NIOSH made modifications to the table and vented the system to the outdoors. An evaluation was performed. The average ethyl methacrylate exposure in personal breathing zone samples when using the modified table for approximately 6 hours was 0.6 ppm; when using the unventilated conventional table, the average exposure was 8.7 ppm. The difference in the values was statistically significant.
NIOSH Health Hazard Evaluation (HHE) Reports
Warren Tech [PDF – 211 KB]
HHE Report, HETA 2002-0306-2911
The Grand Experience Salon [PDF – 229 KB]
HHE Report, HETA 97-0153-2694
Tina & Angela’s Nail Salon [PDF – 176 KB]
HHE Report, HETA 92-128-2241
Haute Nails [PDF – 167 KB]
HHE Report, HETA 90-048-2253
Chapple Hair Styling Salon [PDF – 190 KB]
HHE Report, HETA 89-138-2215
Journal Article Published by Author of NIOSH-Sponsored Extramural Research
Exposure Assessment in Nail Salons: An Indoor Air Approach
ISRN Public Health Volume 2012 (2012), Article ID 962014, 7 pages
Due to the complexity of the nail salon work environment, traditional approaches to exposure assessment in this context tend to mischaracterize potential hazards as nuisances. For this investigation, a workable “indoor air” approach was devised to characterize potential hazards and ventilation in Boston, Massachusetts area nail salons which are primarily owned and staffed by Vietnamese immigrants. A community-university partnership project recruited salons to participate in a short audit which included carbon dioxide measurements and evaluation of other air quality metrics. Twenty-two salons participated. Seventy-three percent of the salons had spot carbon dioxide measurements in excess of 700 ppm, the level corresponding to a ventilation rate recommended for beauty salons. Fourteen salons (64%) did not have a mechanical ventilation system to provide fresh air and/or exhaust contaminated air. The lack of adequate ventilation is of significant concern because of the presence of potentially hazardous chemicals in salon products and the common self-report of symptoms among nail technicians. Community and worker health may be improved through adoption of recommended ventilation guidelines and reduction in the hazard potential of nail products.
Results from a community-based occupational health survey of Vietnamese-American nail salon workers
J Immigrant Minority Health (2008) 10:353–361.
A community-university collaborative partnership assessed self-reported work-related health effects and environmental factors in Boston’s Vietnamese immigrant community via an interviewer-assisted survey. Seventy-one nail technicians responded. Musculoskeletal disorders, skin problems, respiratory irritation and headaches were commonly reported as work-related, as were poor air quality, dusts and offensive odors. The reporting of a work-related respiratory symptom was significantly associated with the reporting of exposure factors such as poorer air quality. Absence of skin disorders was associated with glove use and musculoskeletal symptoms were associated with years worked as a nail technician. Work-related health effects may be common in nail salon work. Chemical and musculoskeletal hazards should be reduced through product and equipment redesign.
NIOSH Science Blog
Nail Salon Table Evaluation
The OSHA website covering Health Hazards in Nail Salons includes information and steps that nail salon workers and employers can take to prevent injuries and illnesses. Information is also available for workers in OSHA’s publication “Stay Healthy and Safe While Giving Manicures and Pedicures: A Guide for Nail Salon Workers,” also available through this website.
California Safe Cosmetics Program Product Database
Cheryl Estill, MS, PE
NIOSH Industrial Hygiene Supervisor
Jack (Ming-Lun) Lu, PhD
NIOSH Research Ergonomist