Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Pearls
ARTICLE IN PRESS
doi:
10.25259/IJDVL_13_2022

Single injection technique for the management of both nail-matrix and nail-bed lesions of inflammatory nail disorders

Department of Dermatology and STD, University College of Medical Sciences & GTB Hospital, Dilshad Garden, Delhi, India
Corresponding author: Prof Archana Singal, Department of Dermatology and STD, University College of Medical Sciences & GTB Hospital, Dilshad Garden, Delhi, India. archanasingal@hotmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Singal A. Single injection technique for the Management of both nail-matrix and nail-bed lesions of inflammatory nail disorders. Indian J Dermatol Venereol Leprol doi: 10.25259/IJDVL_13_2022

Problem

Nail unit involvement is commonly seen with or without co-existent skin lesions in various inflammatory dermatoses. Treatment of isolated nail lesions is often challenging. The efficacy of topical treatment is limited as the densely keratinised nail plate and the thick, double-sided skin in the nail folds prevent the topical drug’s optimal bioavailability. Oral drugs and biologics, on the other hand, have the potential for significant systemic toxicity and their use may not be justified in isolated nail involvement. In addition, the slow growth of diseased nail plates in many of these conditions, necessitates longer course of treatment affecting compliance. Intralesional therapy offers many advantages in isolated nail disease; it is targeted, the drug is deposited at the site of pathology in higher concentration and it also avoids drug interactions and systemic side effects. Furthermore, no specialized drug formulation or equipment is required. Many agents including triamcinolone acetonide, methotrexate and ciclosporin have been used for intra-matricial and/or nail bed injection depending upon the site of pathology in diseases like nail psoriasis and nail lichen planus. In many of these conditions, pathology exists in both the nail matrix and nail bed. Intra-matricial and intra-bed injections of corticosteroids (triamcinolone acetonide 5 mg/ml) have been recommended as a first line, low-risk procedure for inflammatory nail diseases including psoriasis.1,2 The standard procedure for intra-matricial injection, involves inserting the needle 2–3 mm proximal to the junction of proximal and lateral nail folds and taking it horizontally to the centre or alternatively the injection is given at two points for fingers and three points for thumb/toenails [Figure 1].1 For bed injection, the needle is inserted from proximal nail fold through the matrix into the bed [Figure 1].3 Both intra-matricial/ bed injections are associated with moderate to severe pain for which prior application of cold packs and/or a vibratory device have been advised with limited success.3 Mittal et al. have also proposed two additional pricks of the proximal digital block using 2% xylocaine.4 Therefore, despite good efficacy, the significant pain associated with multiple needle pricks during intra-matricial and bed injections is a strong deterrent for both physician and the patients.

Figure 1:: Diagrammatic representation of nail unit anatomy and the site of intramatricial injections (two deep blue stars or light blue line) and intra-bed injection (Red line). Green line depicts the course of single injection technique. Please note that the dotted lines indicate the course of needle under the skin. (LNF - lateral nail fold, PNF - proximal nail fold)

Solution

A simple yet very effective technique is to combine intra-matricial and intra bed injection with one needle prick. A 30-gauge needle with the bevel side up is inserted at an angle of 30–45 degrees, 2–3 mm proximal to the centre point of the proximal nail fold, directly into the matrix. At this point, approximately 0.05 ml of the drug solution is injected as appreciable by the blanching of the proximal and distal matrix region (lunula). Thereafter, along the same track the needle is advanced distally, and 0.05 ml of drug solution is deposited into the nail bed leading to blanching of the proximal 2/3rd of the nail bed [Video 1]. The anatomic contiguity allows slow and passive diffusion of the drug in the distal 1/3rd of the nailbed too. This single prick technique is simple yet effective [Figure 2] and is relatively less painful as it avoids the traversing of needle from the lateral nail fold to the centre and/or multiple separate pricks for both matrix and nail bed injection.

Video 1: Demonstrates the insertion of 30-gauge needle into the centre of matrix underlying proximal nail fold and then into the nail bed leading to the visible blanch of lunula and proximal 2/3rd of the nail bed.
Figure 2:: a - biopsy proven case of nail psoriasis in an adult male, b - visible blanch of lunula and nail bed of the left ring finger just after the 4th triamcinolone acetonide injection, c - significant resolution of nail lesions after 4 sessions

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , . Intralesional injection for inflammatory nail diseases. Dermatol Surg. 2016;42:257-60.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , , , et al. Recommendations for the definition, evaluation, and treatment of nail psoriasis in adult patients with no or mild skin psoriasis: A dermatologist and nail expert group consensus. J Am Acad Dermatol. 2019;81:228-40.
    [CrossRef] [PubMed] [Google Scholar]
  3. , . A compendium of intralesional therapies in Nail disorders. Indian Dermatol Online J. 2018;9:373-82.
    [CrossRef] [PubMed] [Google Scholar]
  4. , . Intramatricial injections for nail psoriasis: An open-label comparative study of triamcinolone, methotrexate, and cyclosporine. Indian J Dermatol Venereol Leprol. 2018;84:419-23.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
2,996

PDF downloads
327
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections