Artificial fingernails:
Too hot to handle

By Ulfat Shaikh, MD, MPH, and Anne T. Nucci, MD

Artificial fingernails are all the rage among adolescents, but those who wear them may be playing with fire—literally. Educating yourself and your patients about the health and safety risks of acrylic nails, including the previously undocumented danger reported here, could prevent potentially disfiguring complications.

In this rapidly changing world, primary care pediatricians have to continually expand their fund of knowledge. Keeping abreast of adolescent fads is part of that process. In addition to making observations about body habitus, acne, and affect when an adolescent comes to the office, pediatricians now have to pay attention to tattoos, hair weaving, and body piercing.

One more fad of which we need to be aware is acrylic fingernails. These seemingly benign fashion statements have troublesome side effects. Cases of infection, dermatitis, and disrupted growth of the nail bed have all been reported. We recently encountered an additional, previously undocumented danger associated with the use of artificial nails.

Case report:
Playing with fire

A 16-year-old female presented to our pediatric emergency room with pain of the left index finger. The patient, who had acrylic nails, said that she had been grabbing a pot off the gas burner while making dinner when the nail tip of her left middle finger suddenly caught fire! The acrylic nail rapidly melted down to the nail bed, and the flame spread to the left index finger before the patient could get her hand under cold water. She sustained second degree burns to her left index finger and the distal phalanx of her left middle finger.

Once the patient's artificial nails were removed, her wounds were cleaned and dressed. The burns healed well, and the patient decided against wearing acrylic tips in the future.

Since this occurrence, similar incidents have been reported to our adolescent health center by female patients wearing acrylic nails and using cigarette lighters.

Faux fingernails:
The hard facts

There are three types of acrylic nails: One, nails that are repaired by wrapping them with silk or linen that is bonded to the nail plate with acrylic glue. Two, plastic nails that are secured to the nail plate with acrylic glue. And three, "sculptured" nails formed with various acrylate polymers that are shaped or sculptured onto the surface of the nail plate.¹ (Figure 1 illustrates the anatomy of a natural nail.)

When acrylic nails were initially formulated they contained a methyl methacrylate monomer, which was found to cause severe contact dermatitis, paronychia, and nail dystrophy. The Food and Drug Administration banned the use of methyl methacrylate monomers in artificial nails in 1974.² Another acrylic, ethyl cyanoacrylate (Krazy Glue), is still used to repair breaks in the nail plate. It used to be thought that cyanoacrylates could not become allergens, but now we know that cyanoacrylates, applied to the nail, can cause nail dystrophy, inflammation and shedding of the nail, paronychia, and even permanent nail loss.³ In addition to causing periungual eczema, cyanoacrylate allergy is associated with nummular lesions over the hands and forearms and with eczema at more distant sites, including the eyelids. These rashes suggest transmission of the allergenic "dust" during the process of acrylic nail filing.⁴

Another feature of the allergic contact dermatitis caused by acrylic monomers is a distressing paresthesia of the fingertips—a burning sensation, tingling, and numbness. It may persist for several weeks after the dermatitis has subsided.⁵ According to one report, a woman had complete loss of fingernails, paronychial tenderness, and paresthesia of the fingertips, all of which persisted for the 16 years that she was followed up.⁶ This followed the use of the infamous methyl methacrylate monomer.

Acrylic nails lengthen the nail plate, and longer nails are subject to greater and more frequent trauma, sometimes causing the nail plate to separate from the underlying nail bed. In addition, when acrylic nails are first applied, the surface of the natural nail plate is often abraded to improve bonding of the acrylic. When the artificial nails are removed, the surface layers of the nail are subjected to further injury.¹

The dangers of acrylic nails are not limited to external insults. Methemoglobinemia has been reported in a 16-month-old who drank a solution containing N,N-dimethyl-p-toluidine; her grandmother, a professional manicurist, was using the solution to make artificial fingernails.⁷ Serious (and one fatal) cyanide poisonings have occurred when children have ingested sculpted-nail-remover solvents, which contain acetonitrile and other nitriles. These chemicals are slowly metabolized in the body to cyanide, so that less serious manifestations of the ingestion—such as tachycardia, headache, and drowsiness—usually occur several hours later, sometimes after the child has been sent home from a medical facility.^8,9

The nail itself can pose a danger to young children. There is a case report of an infant presenting with fussiness, drooling, and refusal of bottles for one day who turned out to have an artificial nail stuck to her hard palate. Her mother had tried to soothe the child during a crying spell by offering her right index finger in place of a pacifier. Although the mother knew she had lost one of her artificial nails, she was unaware that it had become detached when her infant was sucking on her finger.¹⁰

Acrylic nails have also been implicated in the transmission of infection. For that reason, health-care workers should be advised against wearing sculptured acrylic nails. A greater number of gram-negative rods have been cultured—after handwashing—from the fingertips of nurses with artificial nails than from those of nurses with natural nails.^11,12 As Kechijian describes,¹ a normal nail plate is markedly permeable to water. When hands are immersed in liquids and then removed, water readily evaporates through the nail plate. With acrylic nails, evaporation is impeded, and the nail plate and nail bed tend to remain hydrated for prolonged periods of time. As a result of this protracted exposure to a damp environment, the nail bed is more likely to separate from the nail plate, increasing the nail's susceptibility to bacterial and yeast infections.¹

Where there's smoke, there could be fire

Acrylic nails are associated with potentially dangerous side effects (Table 1). As primary care providers to the style-conscious teenager, it is incumbent upon us to warn our patients of the possibility of permanently disfiguring complications. When we see an adolescent with acrylic nails in our office, we may want to discuss some of the adverse effects as part of our anticipatory guidance. Even if our advice doesn't deter her from wearing acrylic tips, it may at least deter her from smoking!

TABLE 1
Acrylic nails What are the risks?

REFERENCES

1. Kechijian P: Dangers of acrylic fingernails. JAMA 1990;263(3):458

2. US District Court Decision: UC vs. CEB Products, Inc., 380F. Suppl. 664(N.D. 111, 1974)

3. Freeman S, Lee M, Gudmundsen K: Adverse contact reactions to sculptured acrylic nails: Four case reports and a literature review. Contact Dermatitis 1995;33:3817

4. Belsito DV: Contact dermatitis to ethyl-cyanoacrylate-containing glues. Contact Dermatitis 1987;17:234

5. Fisher AA: Adverse nail reactions and paresthesia from "photobonded acrylate 'sculptured' nails." Cutis 1990;45:293

6. Fisher AA: Permanent loss of fingernails due to allergic reaction to an acrylic nail preparation: A sixteen-year follow-up study. Cutis 1989;43:404

7. Potter JL, Krill CE, Neal D, et al: Methemoglobinemia due to ingestion of N,N-dimethyl-p-toluidine, a component used in the fabrication of artificial fingernails. Ann Emerg Med 1988;17:1098

8. Caravati EM, Litovitz TL: Pediatric cyanide intoxication and death from an acetonitrile-containing cosmetic. JAMA 1988;260:3470

9. Kurt IL, Day LC, Reed WG, et al: Cyanide poisoning from sculpted nail remover. Vet Hum Toxicol 1989; 31:339

10. Vogeley EV: Danger of artificial nails (Letter). Pediatrics 1999;104:132

11. Senay H: Acrylic nails and transmission of infection. Canadian Journal of Infection Control 1991;6:52

12. Moolenaar RL, Crutcher JM, et al: A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: Did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol 2000;21(2):80

DR. SHAIKH is Assistant Professor of Pediatrics, University of Nevada School of Medicine, Las Vegas. She was Pediatric Resident, Department of Pediatrics, Bronx-Lebanon Hospital Center, NY, at the time this article was written.

DR. NUCCI is Assistant Professor of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, and Director, Division of Adolescent Medicine, Department of Pediatrics, Bronx-Lebanon Hospital Center, NY.

 

Ulfat Shaikh, Anne Nucci. Artificial fingernails: Too hot to handle. Contemporary Pediatrics 2000;11:99.