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Nail cosmetics: Potential hazards
This month’s selected commentary
Nail cosmetics: Potential hazards Warren R. Heymann, MD Based on the dialogue ‘‘Nail cosmetics’’ between Giuseppe Militello, MD, and Richard Scher, MD Dialogues in Dermatology, a monthly audio program from the American Academy of Dermatology, contains discussions between dermatologists on timely topics. Commentaries from Dialogues Editorin-Chief Warren R. Heymann, MD, are provided after each discussion as a topic summary and are provided here as a special service to readers of the Journal of the American Academy of Dermatology. ( J Am Acad Dermatol 2007;57:1069-70.)
T
he desire for beautiful nails is a universal phenomenon. More than $6 billion was spent in the United States on nail salon services in 2004. Problems related to nail cosmetics include those related to the cosmetic materials themselves or those related to the procedures used to adorn nails (ie, cleaning the nails with a brush and an orange stick or removing the cuticles with nippers and pushers), which may result in traumatic injury to the nail unit or secondary infections.1 Contact dermatitis of the nail unit is not a rare event. It may present as onychodystrophy, onycholysis, paronychia, or as dermatitis on other cutaneous sites. According to Dr Militello, ‘‘The most common allergens are found in nail cosmetics such as enamel, sculptured nails, and preformed plastic tips. Toluene sulfonamide formaldehyde resin, acrylates, and ethylcyanoacrylate are the most common allergens.’’ Irritant dermatitis may also be seen with nail hardener solvents such as formaldehyde; nail enamel removers, including acetone or alcohol; the nail primer methacrylic acid for sculptured nails; and the cuticle removers sodium hydroxide and potassium hydroxide.2 Aside from the localized dermatologic adverse effects caused by nail cosmetics and their accoutrements, there are potential associated hazards. In a 2004 report by the American Association of Poison Control Center, exposures to cosmetics and personal care products were the most common poisons in the pediatric population, and third among adults, after analgesics and cleansing agents, respectively. Nail products, including polish, polish removers, and ‘‘artificial nail’’ adhesives, were all responsible
The statements and opinions expressed in this commentary are those of the Editor-in-Chief of Dialogues in Dermatology.
agents.3 Brown and Nanayakkara4 report the case of a 15-month-old girl who became comatose after sucking on nail polish remover pads, the main ingredient of which was gamma butyrolactone. The patient’s course was complicated by upper airway obstruction, bilateral pneumothoraces, and pneumomediastinum. After 5 days of ventilator support, the child had a complete recovery. Nail technicians who have been exposed to solvents and methacrylates have been found to experience cognitive and neurologic symptoms.3 Gallagher et al5 reported 3 female nail technicians who developed respiratory symptoms (wheezing and chest tightness) presumably because of exposure to acrylic resins. McNary and Jackson6 state that ‘‘There is a growing concern that chemical exposure from consumer products including cosmetics adds to the overall toxic exposure bioburden.’’ The authors quantified the actual amount of formaldehyde and toluene exposure to professional nail technicians and their customers during the application of cosmetic nail products containing these chemicals. Their results demonstrated that neither workers nor consumers are at any additional risk from exposure to these agents beyond daily exposure from commercial products in a work setting or in the home. An intriguing question is whether nail polish affects pulse oximeter readings. This could have profound implications in the intensive care unit. Chan et al7 found an approximately 2% decrease in the measurement of oxygen saturation in fingernails painted with either black or brown fingernail polish when measured with the probe in the top-to-bottom position. Using the probe in a side-to-side position, however, precluded any minor effects that fingernail polishes may have rendered, thereby obviating the need to remove the polish. Rodden et al8 studied the 1069
1070 Dialogues in Dermatology
J AM ACAD DERMATOL DECEMBER 2007
absorption spectra of 10 nail polish colors by using spectrophotmetry. The mean oxygen saturation was measured on each of the 10 nails of healthy volunteer by pulse oximetry (utilizing two different devices), with and without nail polish, using a sideto-side configuration. For both machines, there was a statistically significant decrease in oxygen saturation for brown and blue polish; red polish caused a statistically significant decrease in one machine. The authors emphasize, however, that these changes were less than 1%, and this is not believed to be clinically relevant. Nail adornments may hinder the working ability of health care workers. Long fingernails may reduce grip and decrease the speed of manipulation. Other potential problems include glove puncture and catching nails in machinery, bedding, or dressings.9 According to Dahdah and Scher,3 a concern of the use of artificial nails is their tendency to harbor bacteria that are difficult to eliminate by cleansing with antimicrobial soaps or alcohol-based gels. ‘‘This makes their use by health care workers potentially hazardous, with an increase in the likelihood of transmitting infections. The Association of Operating Nurses recommends that surgical personnel keep their nails short and unadorned.’’ Is it safe for health care workers to polish their nails? Arrowsmith et al10 surveyed all studies published on this topic up to November 2000. The authors found no trials of nail polish wearing or removal that measured patient outcomes, including surgical infection. The authors assert that there is insufficient evidence to substantiate the effect of wearing nail polish on the number of bacteria on the skin. They conclude that there is no evidence that removing nail polish has any bearing on the risk of surgical wound infections. Future studies will be necessary to confirm this conclusion. Although I appreciate looking at beautiful nails in a social context, polish and other adornments may mask diagnostic clues in an otherwise thorough dermatologic examination. As Sir Arthur Conan Doyle’s Sherlock Holmes stated, ‘‘I can never bring you to realize the importance of sleeves, the suggestiveness of thumb-nails, or the great issues that may hang from a boot-lace.’’ As the popularity of nail art
increases, I cannot help but wonder what disorders, including subungual melanomas, will go undiagnosed. At the very least, we should remind our patients to examine their nails at those times when they are unadorned. REFERENCES 1. Rich P. Nail cosmetics. Dermatol Clin 2006;24:393-9. 2. Militello G. Contact and primary irritant dermatitis of the nail unit diagnosis and treatment. Dermatol Ther 2007;20:47-53. 3. Dahdah MJ, Scher RK. Nail diseases related to nail cosmetics. Dermatol Clin 2006;24:233-9. 4. Brown JJ, Nanayakkara CS. Acetone-free nail polish removers: are they safe? Clin Toxicol 2005;43:297-9. 5. Gallagher F, Gaubert D, Hale M. Respiratory hazards of ‘‘nail sculpture.’’ BMJ 2003;327:1050. 6. McNary JE, Jackson EM. Inhalation exposure to formaldehyde and toluene in the same occupational and consumer setting. Inhal Toxicol 2007;19:573-6. 7. Chan MM, Chan MM, Chan ED. What is the effect of fingernail polish on pulse oximetry? Chest 2003;123:2163-4. 8. Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intens Crit Care Nurs 2007; 23:51-5. 9. Jeanes A, Green J. Nail art: a review of current infection control issues. J Hosp Infect 2001;49:139-42. 10. Arrowsmith VA, Maunder JA, Sargert RJ, Taylor R. Removal of nail polish and finger rings to prevent surgical infection. Cochrane Database Syst Rev 2001;4:CD003325.
Additional topics from the November 2007 issue of the Dialogues in Dermatology: 1. How to manage ‘‘difficult’’ patients With Barry Resnik, MD, interviewed by Stuart Brown, MD 2. Cosmeceuticals With Carl Thornfeldt, MD, interviewed by Maurice Thew, MD Dialogues in Dermatology is published monthly by the American Academy of Dermatology in both audio cassette and CD formats. Corporate and editorial offices: 930 E Woodfield Dr, Schaumburg, IL 60173-4729. 2007 subscription rates: $150 for individuals in the United States, Canada, and Mexico; $200 International. Ó 2007 by the American Academy of Dermatology, Inc. Subscriptions are available by calling toll-free: 866-503-7546 or faxing 847-240-1859. Additional information is available in the Marketplace section of www.aad.org.
Nail cosmetics: Potential hazards Warren R. Heymann, MD Based on the dialogue ‘‘Nail cosmetics’’ between Giuseppe Militello, MD, and Richard Scher, MD Dialogues in Dermatology, a monthly audio program from the American Academy of Dermatology, contains discussions between dermatologists on timely topics. Commentaries from Dialogues Editorin-Chief Warren R. Heymann, MD, are provided after each discussion as a topic summary and are provided here as a special service to readers of the Journal of the American Academy of Dermatology. ( J Am Acad Dermatol 2007;57:1069-70.)
T
he desire for beautiful nails is a universal phenomenon. More than $6 billion was spent in the United States on nail salon services in 2004. Problems related to nail cosmetics include those related to the cosmetic materials themselves or those related to the procedures used to adorn nails (ie, cleaning the nails with a brush and an orange stick or removing the cuticles with nippers and pushers), which may result in traumatic injury to the nail unit or secondary infections.1 Contact dermatitis of the nail unit is not a rare event. It may present as onychodystrophy, onycholysis, paronychia, or as dermatitis on other cutaneous sites. According to Dr Militello, ‘‘The most common allergens are found in nail cosmetics such as enamel, sculptured nails, and preformed plastic tips. Toluene sulfonamide formaldehyde resin, acrylates, and ethylcyanoacrylate are the most common allergens.’’ Irritant dermatitis may also be seen with nail hardener solvents such as formaldehyde; nail enamel removers, including acetone or alcohol; the nail primer methacrylic acid for sculptured nails; and the cuticle removers sodium hydroxide and potassium hydroxide.2 Aside from the localized dermatologic adverse effects caused by nail cosmetics and their accoutrements, there are potential associated hazards. In a 2004 report by the American Association of Poison Control Center, exposures to cosmetics and personal care products were the most common poisons in the pediatric population, and third among adults, after analgesics and cleansing agents, respectively. Nail products, including polish, polish removers, and ‘‘artificial nail’’ adhesives, were all responsible
The statements and opinions expressed in this commentary are those of the Editor-in-Chief of Dialogues in Dermatology.
agents.3 Brown and Nanayakkara4 report the case of a 15-month-old girl who became comatose after sucking on nail polish remover pads, the main ingredient of which was gamma butyrolactone. The patient’s course was complicated by upper airway obstruction, bilateral pneumothoraces, and pneumomediastinum. After 5 days of ventilator support, the child had a complete recovery. Nail technicians who have been exposed to solvents and methacrylates have been found to experience cognitive and neurologic symptoms.3 Gallagher et al5 reported 3 female nail technicians who developed respiratory symptoms (wheezing and chest tightness) presumably because of exposure to acrylic resins. McNary and Jackson6 state that ‘‘There is a growing concern that chemical exposure from consumer products including cosmetics adds to the overall toxic exposure bioburden.’’ The authors quantified the actual amount of formaldehyde and toluene exposure to professional nail technicians and their customers during the application of cosmetic nail products containing these chemicals. Their results demonstrated that neither workers nor consumers are at any additional risk from exposure to these agents beyond daily exposure from commercial products in a work setting or in the home. An intriguing question is whether nail polish affects pulse oximeter readings. This could have profound implications in the intensive care unit. Chan et al7 found an approximately 2% decrease in the measurement of oxygen saturation in fingernails painted with either black or brown fingernail polish when measured with the probe in the top-to-bottom position. Using the probe in a side-to-side position, however, precluded any minor effects that fingernail polishes may have rendered, thereby obviating the need to remove the polish. Rodden et al8 studied the 1069
1070 Dialogues in Dermatology
J AM ACAD DERMATOL DECEMBER 2007
absorption spectra of 10 nail polish colors by using spectrophotmetry. The mean oxygen saturation was measured on each of the 10 nails of healthy volunteer by pulse oximetry (utilizing two different devices), with and without nail polish, using a sideto-side configuration. For both machines, there was a statistically significant decrease in oxygen saturation for brown and blue polish; red polish caused a statistically significant decrease in one machine. The authors emphasize, however, that these changes were less than 1%, and this is not believed to be clinically relevant. Nail adornments may hinder the working ability of health care workers. Long fingernails may reduce grip and decrease the speed of manipulation. Other potential problems include glove puncture and catching nails in machinery, bedding, or dressings.9 According to Dahdah and Scher,3 a concern of the use of artificial nails is their tendency to harbor bacteria that are difficult to eliminate by cleansing with antimicrobial soaps or alcohol-based gels. ‘‘This makes their use by health care workers potentially hazardous, with an increase in the likelihood of transmitting infections. The Association of Operating Nurses recommends that surgical personnel keep their nails short and unadorned.’’ Is it safe for health care workers to polish their nails? Arrowsmith et al10 surveyed all studies published on this topic up to November 2000. The authors found no trials of nail polish wearing or removal that measured patient outcomes, including surgical infection. The authors assert that there is insufficient evidence to substantiate the effect of wearing nail polish on the number of bacteria on the skin. They conclude that there is no evidence that removing nail polish has any bearing on the risk of surgical wound infections. Future studies will be necessary to confirm this conclusion. Although I appreciate looking at beautiful nails in a social context, polish and other adornments may mask diagnostic clues in an otherwise thorough dermatologic examination. As Sir Arthur Conan Doyle’s Sherlock Holmes stated, ‘‘I can never bring you to realize the importance of sleeves, the suggestiveness of thumb-nails, or the great issues that may hang from a boot-lace.’’ As the popularity of nail art
increases, I cannot help but wonder what disorders, including subungual melanomas, will go undiagnosed. At the very least, we should remind our patients to examine their nails at those times when they are unadorned. REFERENCES 1. Rich P. Nail cosmetics. Dermatol Clin 2006;24:393-9. 2. Militello G. Contact and primary irritant dermatitis of the nail unit diagnosis and treatment. Dermatol Ther 2007;20:47-53. 3. Dahdah MJ, Scher RK. Nail diseases related to nail cosmetics. Dermatol Clin 2006;24:233-9. 4. Brown JJ, Nanayakkara CS. Acetone-free nail polish removers: are they safe? Clin Toxicol 2005;43:297-9. 5. Gallagher F, Gaubert D, Hale M. Respiratory hazards of ‘‘nail sculpture.’’ BMJ 2003;327:1050. 6. McNary JE, Jackson EM. Inhalation exposure to formaldehyde and toluene in the same occupational and consumer setting. Inhal Toxicol 2007;19:573-6. 7. Chan MM, Chan MM, Chan ED. What is the effect of fingernail polish on pulse oximetry? Chest 2003;123:2163-4. 8. Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intens Crit Care Nurs 2007; 23:51-5. 9. Jeanes A, Green J. Nail art: a review of current infection control issues. J Hosp Infect 2001;49:139-42. 10. Arrowsmith VA, Maunder JA, Sargert RJ, Taylor R. Removal of nail polish and finger rings to prevent surgical infection. Cochrane Database Syst Rev 2001;4:CD003325.
Additional topics from the November 2007 issue of the Dialogues in Dermatology: 1. How to manage ‘‘difficult’’ patients With Barry Resnik, MD, interviewed by Stuart Brown, MD 2. Cosmeceuticals With Carl Thornfeldt, MD, interviewed by Maurice Thew, MD Dialogues in Dermatology is published monthly by the American Academy of Dermatology in both audio cassette and CD formats. Corporate and editorial offices: 930 E Woodfield Dr, Schaumburg, IL 60173-4729. 2007 subscription rates: $150 for individuals in the United States, Canada, and Mexico; $200 International. Ó 2007 by the American Academy of Dermatology, Inc. Subscriptions are available by calling toll-free: 866-503-7546 or faxing 847-240-1859. Additional information is available in the Marketplace section of www.aad.org.