If you’re concerned about a nail disorder, like a fungal infection, a nail biopsy might be just what your doctor orders. After all, diagnosing nail problems accurately is key to treating them effectively.
One of the most common reasons for a nail biopsy is to diagnose onychomycosis, also known as a fungal nail infection.
So, what exactly goes into a nail biopsy for fungus? This article will walk you through the indications, the different techniques, and all the important things to consider when performing a nail biopsy to figure out if a fungal infection is the culprit.
Picking the right biopsy technique is crucial. It all depends on what your doctor suspects is going on underneath the surface and exactly where the infection seems to be located. Getting the technique just right helps keep complications to a minimum and ensures the biopsy gives your doctor the best possible information.
It’s not just the doctor involved, either. Nail biopsies really shine when dermatologists, podiatrists, nurses, and other healthcare pros all work together. This team effort makes the whole process smoother and more effective.
We’ll also dive into the nitty-gritty of nail anatomy, how to get ready for the biopsy, and what kind of care you’ll need afterward. Plus, we’ll touch on the importance of staining those biopsy samples just right – think PAS stain – to make sure any fungal organisms lurking are easy to spot.
Understanding the Nail Unit
A nail biopsy can help diagnose certain conditions, including nail fungus. To understand a nail biopsy, it helps to know something about the anatomy of the nail.
Key components of the nail unit
- Nail plate: The hard part of your nail. It’s translucent, so you can see the nail bed underneath. The nail plate protects the tissues underneath and helps you grasp objects.
- Nail bed: The skin underneath the nail plate. It supports the nail plate and nourishes it.
- Nail matrix: The base of the nail where nail growth starts. If the matrix gets damaged, it can cause the nail to grow in a distorted way.
- Nail folds: The skin folds around the nail plate. These include the proximal nail fold (PNF) at the base of the nail and the lateral nail folds (LNF) on the sides of the nail.
- Hyponychium: The area under the free edge of the nail plate (the part you trim).
Why anatomical knowledge matters for a nail biopsy
Knowing the anatomy of the nail is essential for a successful nail biopsy. To get an accurate diagnosis, the healthcare provider needs to target a specific nail structure, such as the plate, bed, or matrix.
It’s also important to avoid damaging the nail matrix during a biopsy. Damage to the matrix can cause permanent deformities in the way the nail grows.
When is a nail biopsy needed to diagnose a fungal infection?
Sometimes, it’s obvious you have a fungal nail infection. Other times, it’s not so clear. Here are some of the reasons your doctor might recommend a nail biopsy, even if you’ve already had other tests:
- When other tests are inconclusive. Even if a non-invasive keratin biopsy comes back negative for onychomycosis, a nail biopsy can provide a more definitive answer.
- When the infection doesn’t look like a typical fungal infection. Sometimes, the infection has an atypical presentation that doesn’t quite fit the usual pattern.
- To rule out other nail problems. Conditions like psoriasis and lichen planus can look a lot like onychomycosis. A biopsy can help your doctor differentiate between them.
- Before you start taking antifungal medication. Since antifungal drugs can have toxic side effects, your doctor will want to be absolutely sure you have a fungal infection before prescribing them. Is Dr. Berg’s approach to nail fungus right for you?
- When antifungal medications don’t work. If you’ve tried antifungal medications and they haven’t helped, a biopsy can determine if the fungus is resistant to the medication or if you have a different condition altogether; alternatively, you may want to consider CO2 laser for toenail fungus treatment.
- To determine the specific type of fungal infection. Different types of fungi require different treatments, so identifying the specific species is crucial.
- When you have nail dystrophy and the cause is unknown. Nail dystrophy refers to abnormalities in nail growth or appearance. A biopsy can help determine if a fungus is the underlying cause.
When a Nail Biopsy Might Not Be a Good Idea
While nail biopsies are generally safe, there are situations where they’re best avoided. Your doctor will carefully consider your overall health before recommending one. Here are some conditions that might make a nail biopsy risky:
- Peripheral vascular disease (PVD): If you have poor circulation, it can increase the risk of complications during and after the biopsy.
- Arterial compromise: Similar to PVD, compromised arteries can hinder healing and raise the risk of infection.
- Severe bleeding disorders: These can lead to excessive bleeding after the procedure.
- Active infection at the biopsy site: A biopsy could spread the infection further.
- Weakened immune system: If you’re immunocompromised, you’re more vulnerable to infection and slower healing.
Your doctor will also proceed with extra caution if you have collagen vascular disease or diabetes.
Equipment and Materials
If you’re going to have a nail biopsy done, your doctor will need a specific set of tools and materials to perform the procedure safely and effectively. Here’s a list of what they’ll need:
- Sterile gloves and drapes
- Antiseptic solution (like chlorhexidine or povidone-iodine)
- Local anesthetic (such as lidocaine)
- Syringe and needle for the local anesthetic
- Biopsy punch (in different sizes) or a scalpel
- Nail nippers or a nail elevator to remove the nail
- Hemostatic agents (like aluminum chloride) to stop bleeding
- Sutures (if stitches are needed)
- Sterile dressing and bandage
- A specimen container with formalin to preserve the sample
How to prepare for a nail biopsy
Before your nail biopsy, your doctor will review the procedure with you and explain the risks and benefits. This is a good time to ask any questions you have.
Your doctor will also want to know about your medical history to make sure you don’t have any conditions that would make a nail biopsy risky for you.
Next, your doctor will examine your nail and the skin around it to determine the best place to take the sample.
The area will be cleaned with an antiseptic to prevent infection.
To keep you comfortable, your doctor will inject a local anesthetic to numb your toe or finger. A tourniquet may be used to control bleeding, but it will only stay on for a short time.
If your doctor needs to biopsy your nail bed, they may order an X-ray beforehand.
Nail Biopsy Techniques for Fungal Infections
A nail biopsy can help your doctor figure out if you have a fungal infection, and if so, what kind. There are different ways to take a nail biopsy, depending on where the infection seems to be.
Nail Plate Biopsy
This type of biopsy takes a sample from the nail plate itself.
- Shave Biopsy: The doctor shaves off a thin layer of the nail. This works well for infections on the surface. A non-invasive keratin biopsy is a type of shave biopsy.
- Punch Biopsy: A small, round tool removes a core sample from the nail plate. This gives a deeper sample to look at. Doctors will carefully consider the size (in millimeters) of the biopsy they need.
- Nail Clipping: A small piece of the affected nail is cut off. This is the easiest way, but it might not give enough material for testing.
Nail Bed Biopsy
A nail bed biopsy takes a sample from the skin underneath the nail.
- Punch Biopsy: A core of tissue is removed from the nail bed. The nail usually needs to be removed (avulsion) before the biopsy. A punch biopsy tool or a scalpel can be used.
- Excisional Biopsy: A wedge of tissue is removed from the nail bed. This gives a bigger sample and a better view. The doctor will carefully stitch the area to reduce scarring. Fusiform excisions should be less than 3mm in width.
Nail Matrix Biopsy
The nail matrix is where the nail grows from. Biopsies here are riskier.
- Punch Biopsy: A core of tissue is removed from the nail matrix. This has a high chance of causing permanent nail problems (dystrophy). It should only be done when absolutely necessary.
- Excisional Biopsy: A wedge of tissue is removed from the nail matrix. This has a higher risk of scarring and nail deformities. It needs very careful surgery and stitching. Haneke suggests that instead of always removing the whole nail when there’s a large dark spot, doctors could shave off the top layers of the spot.
Nail Fold Biopsy
The nail fold is the skin around the edges of the nail.
- Punch Biopsy: A core of tissue is removed from the nail fold. This is helpful for diagnosing inflammatory conditions that affect the nail folds.
- Excisional Biopsy: A wedge of tissue is removed from the nail fold. This allows for a larger sample and a better view.
En bloc Biopsy
- En bloc biopsy of the nail complex.
- En bloc excision of the PNF (proximal nail fold).
- Biopsy of the PNF and the LNF (lateral nail fold).
Post-Biopsy Care and Complications
After your nail biopsy, your doctor will give you detailed wound care instructions. But here’s a quick rundown:
- Keep the area clean and dry.
- Change the bandage daily.
You can usually manage any pain with over-the-counter pain relievers. For the first 48 hours, keep your finger or toe elevated to avoid swelling.
While nail biopsies are generally safe, some complications can occur. These include:
- Bleeding
- Infection
- Scarring
- Nail problems
- Ongoing pain
- Inconclusive results
It’s important to attend your follow-up appointment so your doctor can check how you’re healing and discuss the biopsy results. If you notice any signs of infection (increased pain, redness, swelling, pus) before your appointment, call your doctor right away.
Processing and Interpretation of Biopsy Samples
Once the nail biopsy is taken, it’s crucial that it’s processed correctly. The sample needs to be put in formalin right away to “fix” it. This preserves the tissue so the lab can analyze it effectively.
Then, the lab technicians stain the sample. The most common stain for identifying fungus is called Periodic acid-Schiff (PAS). This stain highlights the cell walls of any fungus present.
Another stain that can be used is Gomori methenamine-silver.
Next, a pathologist (a doctor who specializes in diagnosing diseases by examining tissues) will examine the sample under a microscope. They’ll look for fungal elements and determine how widespread the infection is.
Finally, the pathologist’s findings are considered along with your nail’s appearance and symptoms. This helps your doctor determine the best course of treatment.
Enhancing healthcare team outcomes
To get the best results for a nail biopsy, you need a team that works well together. This includes dermatologists, podiatrists, nurses, medical assistants, and pathologists.
Clear communication is essential, so everyone knows what’s going on with the patient and the treatment plan. The team will work together to:
- Educate you on wound care and how to take your medications.
- Assist with the biopsy itself.
- Watch for any signs of infection or other problems.
Conclusion
A nail biopsy can be an important way to diagnose a nail fungus or other problem affecting your nails. Getting the right diagnosis depends on the doctor using the proper technique and choosing the right patients to biopsy. This helps to keep complications to a minimum and increases the chances of getting a useful diagnosis.
A team of professionals, including dermatologists, podiatrists, nurses, and pathologists, all play a vital role in the best possible patient care.
New and better diagnostic techniques, like ultra-high-frequency ultrasounds, may improve the accuracy of nail assessments in the future.
By following established guidelines and best practices, healthcare professionals can use nail biopsies to diagnose and manage nail infections and other nail problems, but what works instead of acetone for nail fungus? When doctors can diagnose a problem early and accurately, it leads to more effective treatment and better results for patients.