Nailing Common, Rare, and Scary Pediatric Nail Conditions and Surgeries

Jane Bellet, MD, professor of dermatology at Duke University, found her passion in running the Duke Nail Clinic for children and adults with nail abnormalities. Each day, she provides both medical and surgical management of nail disorders and is presenting 2 sessions at the 2023 Society for Pediatric Dermatology Meeting in Asheville, North Carolina, July 13-16.

In an interview with Dermatology Times®, Bellet gave a sneak peek of challenging cases and opportunities she will present in the following sessions:

• "Nailing" Pediatric Nails: Common, Rare, and Scary | Friday, July 14
• Tiny Toes, Big Care: Navigating Pediatric Nail Surgery with Confidence | Saturday, July 15

Dermatology Times: What piqued your interest in treating pediatric nail conditions?

Bellet: I think I became interested in nails [because] dermatologists are the experts in skin, hair and nails. But specifically in nails...A while back...I was getting sent kids that needed nail biopsies, and I knew how to do sort of just the basics, and really felt inadequate and wanted to learn more. And so I was very lucky to have a observership given to me by the Council for Nail Disorders (CND), and worked with Dr. Nathaniel Jellinek, who is a great mentor, as are all the members of the CND. They are truly truly amazing and very giving of their time and knowledge. I really just wanted to go to learn about surgery so I could take care of the kids right on their nails. At the end, Dr. Jellinek said, "You know, you have to open a nail clinic now." And I was like, wow. And I'm a pediatric dermatologist. But I did open a nail clinic. And I do see both kids and adults there. And, you know, the adults informed the kiddos and so hopefully I can help both groups. Well, although the adult patients get confused when the sign says pediatric dermatology, they always worry they're in the wrong place.

Dermatology Times: Tell us about patient cases that have been milestones in your practice.

Bellet: One patient that I will be sharing is a nice one that turned out well. You know, I walked in and looked like some horrible growth on this kid's fingernail and I was worried I would need to biopsy it...and at his age would have meant going to the operating room. But when I looked more carefully, I actually wondered whether it was a condition that would not require a biopsy at all. And I was lucky it did turn out that way. And so I am sharing that case because I'm hopeful that if people see that particular condition, they won't either biopsy it which would be unnecessary. And then see that it's a nice way to go.

On the flip side, of course, we have other cases that are really really difficult and a couple of people come to mind. One is a young boy with lichen planus. As I will tell people, my heart sinks when I see them in the office because we don't have super treatments. If you look to the literature, it's mostly intralesional steroids, systemic steroids has the most data. And even that data isn't super, for who responds. Some people do respond, but then recur. Some don't respond at all. And we don't really have anything great beyond that. And, you know, people are looking at other things maybe one of the awesome biologics would happen to help us out, which would be great. And the reason why my heart sinks with them is that sometimes it's really hard to help the appearance of these nails. And it can be, you know, quite disfiguring and frequently, a lot of the ages I'm seeing patients is the parents that are much more worried actually, than the kiddos. This particular young boy was not too bothered, but his parents were really worried. So I think that's one...just being able to guide families and give them good advice. Maybe we can push the envelope and research and get better treatments specifically for lichen planus.

And then of course, they're all the melanonychia patients, which I will talk about as well. Briefly, there's not enough time for [a] real [deep dive into] melanonychia. Real melanonychia would be at least an hour and a half. Just that topic, and I think I give it about 2 minutes. It's difficult in kids because sometimes the nail, the brown stripe, looks very concerning something that we would really be worried about if something similar was on the skin or even on an adult patient. And the good news is that nail unit melanoma, and specifically call it nail unit melanoma, is extremely rare in children. Extraordinarily rare. There have only been about 20 cases in the literature. And even of some of those, some are controversial as to whether they're really melanoma. So I like to share that that actually should put everybody at ease, that it's so rare and so our biggest fear is is infinitesimal. But it is there.

And I think we get nervous to see these funny nails and especially if they're evolving and looking worse and worse and worse. But there are some good long-term studies looking at patients over many years where people do just fine. You know, the issue, of course, is when does somebody transition from when do we consider them pediatric? When do we consider them adult, and there's no magic time or age or puberty or whatever. Nobody can say and that makes it hard because the risk profile is different. As soon as you're an adult, whatever that means. And so, that's, that's a tough one. I would say we do end up by seeing some kids that maybe don't need it, but there's just a lot of anxiety particularly on the part of the parents and the only way we can tell them 100% what it is, is to do a biopsy. It's a sort of a tough one. I think that's probably the one that comes up the most in the clinic. But I would say those 3 years sort of interesting situations.

Dermatology Times: Are there specific nail conditions you see an influx of when school starts?

Bellet: Ingrown nails for teenagers. Little kids usually don't get ingrown nails, but teenagers certainly do and so do adults. And one of the biggest troubles with ingrown nails is whether the shoes fit. Have they bought the right size? Or have they outgrown them? But also sports shoes, so cleats...girls and boys tie them really, really tight because they don't want the shoe to fall off when they're running and kicking, which I totally understand. But if they're prone to ingrown nails, it makes things way way worse. I actually even had a young boy with ingrown nail he was in marching band. So it's not just you know, cleats and athletes, but you know, he was in a very competitive marching band, so it was practically like a sport. He was in severe pain, and we had to help him out.

We do see onychomycosis. So toenail fungus...it is much less common than in adults, but we do see it and it can be treated luckily, in children much more easily than it can in adults, because they don't have years and years of damage to their feet and fungus that's been there 25 years. It's been there briefly. Usually, we're able to treat it very effectively, very quickly. And often sometimes just with topicals, which is nice for children, but they also usually do well with oral medications. And usually don't have too many comorbid conditions like adults do.

Dermatology Times: Which memorable pearls would you like session attendees to take home and put into practice?

Bellet: So certainly, if we need an oral medication, we might use them for nail psoriasis you can start simple, but be aggressive and change medications. If they're not working. It's a little different. Like often I'll give 6 months of something before I see if it works, but for that, you know you're probably going to know in 3 to 4 months and if it's not working, just move right along. Don't delay. So that would be 1 thing, particularly for nail psoriasis. For the surgery talk the most important takeaway I will be giving is they need to be sure the tourniquet is off. End of story. They can mess up everything else, but if they don't take the tourniquet, off the consequences are dire.