Adverse effects of nail cosmetics and how to prevent them

Nail polish

The most common use of nail polish is for the beautification of nails. However, it is also used for strengthening brittle nails and camouflaging discolored and irregular nails. Nail polish is actually a mixture of an assortment of various components as shown in Table 2. Adverse effects related to nail polish can be many. It can lead to nail damage due to its ingredients, the way it has been used, or more importantly, the way it has been removed. Salient nail polish related adverse effects include:

Keratin degranulation

It is a type of pseudo-leukonychia, which can result from nail polish binding and subsequently being removed from the nail plate.^[8] The nail polish interacts with keratin leading to the appearance of white striae [Figure 2]. Clinical presentation can also be in the form of macules or patches on the nail plate. Onychoscopy shows white areas corresponding to the areas of nail plate exfoliation.^[9] The condition can be clinically misdiagnosed as superficial white onychomycosis.^[9] Management includes gentle nail care and avoiding frequent contact with irritant and allergenic grooming products including nail polish and remover.^[10]

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Figure 2:

Pseudoleukonychia or keratin degranulation seen after prolonged nail polish application and removal.

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Allergic contact dermatitis

• This should be suspected in a patient presenting with itching and/or scaling in the periungual region [Figure 3]. However, manifestations may not be limited to the nail unit, but can also occur in distant regions, wherever the nail tends to touch and transfer the allergen. The secondary film formers in nail polish are usually resins, especially Toluene Sulphonamide Formaldehyde Resin (TSFR) [Table 2]. TSFR has traditionally been recognized as the causative factor responsible for most cases of allergic contact dermatitis, including facial dermatitis in women.^[11] The other common allergens include formaldehyde, nitrocellulose,^[12] dibutyl phthalate,^[13] and D and C yellow 11.^[14] Various components of nail polish responsible for contact allergic dermatitis and its manifestations are shown in Table 3.

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Figure 3:

Contact allergic dermatitis involving the periungual area, due to nail polish (ROAT or Repeat Open application Test done). Chronic paronychia with greenish discoloration (chloronychia) can also be seen.

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Table 3: Common sensitizers present in nail cosmetics.

Adverse effect	Nail cosmetic implicated	Causative allergen/agent
Contact dermatitis	Nail polish	Nitrocellulose, formaldehyde, TSFR, dibutyl phthalate, butyl stearate, D and C yellow 11, nickel-based solvents
	Nail adhesives	Methacrylate, ethyl-2-cyanoacrylate
	Acrylic nails	Methacrylate, hydroxyethyl methacrylate, benzoyl peroxide
	Gel nails	2-HEMA and 2-HPMA
	Nail hardeners	Formaldehyde
Onycholysis	Nail polish	TSFR
	Acrylic nails	Methyl acrylate or cyanoacrylate nail glue
	Gel nails	Photo-onycholysis (If patient is taking tetracyclines or doxycycline)
	Nail hardeners	Formaldehyde
Paronychia	Nail polish	Formaldehyde
	Cuticle remover	Sodium and potassium hydroxide
	Gel nails	Cyanoacrylate glue

TSFR: Toluene sulfonamide formaldehyde resin, 2-HEMA: 2-hydroxyethyl methacrylate, 2-HPMA: 2-hydroxypropyl methacrylate

As the most common allergen in nail polish is TSFR, a variety of “toxin-free nail polishes,” free of it, are available. These are promoted as hypoallergenic and contain cellulose, acetate, butyrate, and polyester resins. However, they may contain plasticizers such as dibutyl phthalate for softness and pliability, dissolved in solvents (N-butyl acetate or ethyl acetate). Nail polishes free of toluene, phthalate, and formaldehyde are also available. These contain natural pigments in a water base. An important ingredient of these nail polishes is argan oil. Nevertheless, there are reports of allergic reactions to these “hypoallergenic nail polishes” as well, since most brands can have at least one component that can trigger allergic reactions in individuals. Hence, it is suggested that before their usage, a patch test with specific allergens based on the exact composition of these products may be considered.^[15]

Acetone-based nail polish removers

Acetone is one of the commonly used organic solvents in most of the commonly available nail polish removers.^[7] It is an irritant even at lower concentrations and leads to dry, lustreless nails.^[7] In mild cases, it can also lead to onychoschizia or lamellar splitting of the nail plate [Figure 4]. In more severe cases, irritant dermatitis of the perionychial tissue is possible, especially if kept in contact for a longer period [Figure 5].

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Figure 4:

Lamellar splitting of the distal end of the nail plate (onychoschizia) noticed after nail polish removal (Dermlite DL4 Polarized ×10).

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Figure 5:

Dry, lustreless, brittle nails due to repeated use of acetone-based nail polish remover.

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Artificial nails

Long nails have always been considered a desirable and distinct sign of beauty, throughout human history. This can be achieved with the help of false nails or extensions placed to simulate a true nail. With advancements in this field, various techniques and products have been found useful to produce longer and stronger nails [Table 1]. However, their use is associated with mechanical and chemical adverse effects. Various types of artificial nails and their associated adverse effects are summarized below.

1. Nail tips are preformed tips that can be placed over a preexisting nail and trimmed to the desired shape. Adverse effects associated with their usage include onychoschizia or lamellar splitting of the nail, due to the mechanical tug on the nail plate and traumatic removal [Figure 6]. Due to the fact that nail tips are inflexible, they can lead to onycholysis as well. Cyanoacrylate glues, used as adhesive agents to fix the nail tips to the nail plate surface, can rarely lead to contact allergic dermatitis.

2. Nail wrap refers to the technique of applying linen, fiberglass or silk over the surface of a natural nail plate. This is done using glue, followed by the application of an acrylic coat. They have been used as a remedy for split nail deformity as well. Not many adverse effects have been reported.

3. Sculptured nails are nail substitutes applied over existing nail plates. These can be custom designed as per the size and shape of the nail on which they are to be worn. They can be either acrylic or gel based. Both these types involve a mixture of powder and a solution applied over the nail. It is important to have an understanding of the various materials used in the preparation/application of these nails, to have an insight into the adverse effects associated with them.

   • Acrylic nails are less popular currently due to various reasons including their less than natural appearance.^[7] The application involves strong chemicals and fumes, which are not advisable in pregnancy. The process of application of acrylic nails involves the preparation of a polymerized acrylic by mixing liquid ethyl or isobutyl methacrylate with powdered polymethyl-methacrylate polymer.^[8] A benzoyl peroxide accelerator is used to enhance polymerization. Sometimes, hydroquinone is used to slow down polymerization. The product hardens in 7–9 min and, therefore, needs to be applied quickly onto a chemically roughened nail plate. This application is done to the desired length and shape. A variation of this process involves preformed tips at the distal ends of the nail, making it quicker and less expensive to use. They do not require photocuring.

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Figure 6:

Traumatic nail dystrophy due to removal of nail tips.

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There are various adverse effects associated. Acrylates have been identified as potent allergens, necessitating the implementation of safety measures for the use of these chemicals in various nail techniques.^[23] Over the past few years, there have been an increasing number of reports on allergic contact dermatitis due to acrylates. Among these, 2-Hydroxy-Ethyl Methacrylate (HEMA) is considered to be the main culprit.^[24] HEMA was by far the most common ingredient of nail cosmetics, being present in nearly 60% of the products.

Worn-down nails (over-filed nails) are also an adverse effect seen as a direct consequence of procedure-induced trauma. It is seen typically with acrylic nail removal, where mechanical abrasion is required. The overfilled section of the nail is clinically visible as red in color due to nail plate thinning and the visibility of the nail bed underneath. Linear striations due to back-and-forth filing of nails may also be evident clinically, though better visualized onychoscopically. Dilated capillaries and pinpoint hemorrhages are the other onychoscopic features.

• Gel nails - These are a commonly used cosmetic procedure, used to improve the appearance even in disease-induced nail disfigurement.^[25] They have been used in various indications such as trachyonychia, superficial nail pitting, onychorrhexis, onychoschizia, idiopathic Beau’s lines, and longitudinal ridging with rewarding results.^[3]

Gel nails can lead to allergic contact dermatitis due to acrylates present in the preparation. Freeman et al. reported four cases of contact allergy to acrylates with varied reactions, including nail fold, fingertip, and hand dermatitis and face and neck dermatitis.^[26] In a case series, all patients were found positive on patch testing for HEMA and experienced resolution of dermatitis after removal of their acrylic nails or upon discontinuing work with acrylic gel nails.^[27] Less frequent complications including paronychia, nail dystrophy, and onycholysis have also been reported.^[27] Patients with known acrylate allergy should disclose this information to other medical personnel including dentists and orthopedic surgeons, to avoid potential adverse reactions to procedures other than nail procedures.

Psoriasiform onychodystrophy has been reported to be induced by photo-bonded nails.^[28,29] The patients characteristically present with nail changes suggestive of psoriasis, including onycholysis, splinter hemorrhages, hyperkeratosis, and nail plate thinning [Figure 7]. However, these occur as a consequence of gel manicures. Over a period of time, as nails grow, the gel nails require in-fillings[Figure 8]. Since gel manicures and pedicures are on the rise, these changes are also more commonly reported, necessitating the formulation of recommendations to avoid these complications.

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Figure 7:

Pseudo-psoriatic nail as seen on onychoscopy. The patient was not a known case of psoriasis. The onset of nail changes was seen after the usage of artificial nails (Dermlite DL4 Polarized ×10).

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Figure 8:

Synthetic nail requiring in-fills at the proximal end.

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Peripheral neuropathy is a relatively rare complication reported with the use of gel nails.^[30] It may be associated with local neuropathy induced by methyl-methacrylate.^[30] The use of ultraviolet light has been linked both with cutaneous malignancy and ocular toxicity. The use of ultraviolet A (UVA) lamps in curing gel nails is the step considered responsible for this. Diffey concluded that although the risk of inducing squamous cell carcinoma from exposure to UVA nail lamps is very low, it should be reduced further by wearing fingerless gloves on lamp exposure.^[31] The scatter of light from the UV light unit onto the eyes has also raised concern regarding ocular toxicity. It may be prudent to use UV filter glasses to protect the eyes. Various important points to be kept in mind while performing gel nails to minimize the adverse effects associated with them are shown in Table 4.

HEMA AND NAIL COSMETICS

HEMA is the most frequently reacting acrylate and is now considered to be an important cause of contact allergic dermatitis.^[32] It is present in dental materials, glues, and printing inks and paints, apart from nail cosmetics. Previously, sensitized patients were more prone to the development of contact allergic dermatitis, including dental personnel, printers, and industry workers in contact with the glue.

HEMA has emerged consistently as the most sensitizing monomer, with HEMA allergic reactions affecting health professionals and users both. The majority of cases of contact allergic dermatitis to HEMA are related to cosmetic nail products including acrylic nails, gel nails, and long-lasting nail polish (gel lacquer) [Figure 9]. These are seen both in nail technicians (considered to be an occupational dermatosis) and in clients/women doing self-applications at home. This has necessitated stringent policies regarding the use of these chemicals in aesthetic procedures.^[33] Due to a large number of patients reporting contact allergy to HEMA in nail cosmetics, the European Union restricted the use of HEMA in nail cosmetics in 2020, permitting it only for professional use. This meant that warnings like “For professional use only” and “Can cause an allergic reaction” were mandated on the package of nail products containing HEMA.^[32]

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Figure 9:

Finger-tip dermatitis in a nail salon worker.

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NAIL COSMETICS AND HEALTHCARE WORKERS

It is well documented that chipped-off nail enamel and long artificial nails can harbor various organisms including Klebsiella, Pseudomonas, and Candida. These can get transmitted to patients since they are difficult to be washed with soap. Hence, the old chipped-off nail polish should be removed, and nails should be kept short by healthcare workers.^[34]

NAIL COSMETICS AND NAIL TECHNICIANS

Nail technicians are exposed to a variety of occupational hazards at the workplace, due to their job profile. Thus, they form an important subset of patients presenting with adverse effects to nail cosmetics. Occupational hazards include those due to bad ergonomics as a large part of their time at work is spent in a bent position. In addition, there are safety hazards related to chemical, physical, and biological factors.

• Ergonomics-wise, a nail salon worker or nail technician’s job entails sitting for prolonged periods, while bending and adopting awkward uncomfortable postures. They report more musculoskeletal injuries due to prolonged sitting and bending.^[35] Neck, back, and hand/wrist pain are common symptoms in nail technicians.

• Chemical exposure in nail technicians including exposure to formaldehyde, toluene, phthalates, and acrylates is a significant occupational hazard.^[36,37] Respiratory diseases can occur from working in nail salons.^[38]

• Handling of sharp instruments may also result in pricks and punctures.

• Infection is a common complication of nail cosmetics. The workers are also exposed to a variety of pathogens including fungi and bacteria from unsterile instruments and cuts and pricks from sharp instruments used in the performance of cosmetic nail procedures.^[39]

Prevention of health hazards among nail salon workers requires efforts to increase knowledge and improve occupational health in nail salons.^[35] Dissemination of education regarding workplace hazards and their impact reduction can go a long way in preventing such outcomes. Improved ergonomics can lead to an immediate improvement in their condition, going a long way in minimizing morbidity. It is important to focus on educating nail salon workers regarding the health hazards of chemical exposure, providing them with the right kind of gloves and ensuring good ventilation at the workplace. The nail technicians should also wear proper well-fitting masks and protective eyewear. At the worksite, there is inevitable contact with nail materials daily. It should be ensured that the tools and work surfaces are free from allergens. Extreme precautions should be taken while performing work to ensure that acrylates do not spread on skin or surrounding surface or equipment, as these can subsequently act as a source of exposure. Suuronen et al. performed a simplified penetration test to evaluate the suitability of disposable glove material to be used in nail salons for protection against methacrylates.^[40] They concluded that neoprene was the best material for protection against gel nail products. Other materials were not found suitable for protection against acrylates which could penetrate through or even degrade the glove material very quickly. Disposable gloves should not be used for handling of acrylic nail liquids. Some uncommon adverse effects of nail cosmetics are shown in Table 5.