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Management of nail disease would improve with an interdisciplinary approach, particularly between dermatologists and podiatrists.

Change is sorely needed in how both professions handle nail disease and disorders, argued the authors of a recent Viewpoint article in .

Those co-authors were Jasmine Rana, MD, clinical assistant professor of dermatology at Stanford School of Medicine in California, and Tracey Vlahovic, DPM, clinical professor with Temple University School of Podiatric Medicine in Philadelphia.

Rana and Vlahovic recently discussed their reasons for writing the Viewpoint with the Reading Room. The exchange has been edited for length and clarity.

You posit in the article headline that there is a need to "rethink the approach to nail disorders." What is it about the status quo that inspired you both to undertake this review?

Rana: Nails don't really "belong" to any one specialty. In taking care of patients with nail disorders, we work at the intersection of podiatry and dermatology.

I am dermatology-trained and Tracey is podiatry-trained. To provide the best care for our patients, I think we both realized there are gaps in specialty-specific models of nail disease.

For example, in dermatology there is often a bias to attribute nail disease to fungus or inflammatory disease like psoriasis instead of acknowledging the role of bunions and hammer toes in nail health.

One motivation for us in writing was sparked by rising rates of antifungal resistance and seeing many patients who come for evaluation of non-fungal nail disease who have had multiple courses of oral and topical antifungals, to no avail.

This is a genuine call to action to reconsider how we are diagnosing and treating nail disease and start to think about the impact on cost to our healthcare system and quality of care for our patients.

The article draws comparisons to the parable of the blind man and the elephant. Can you explain this parable and why it's an apt analogy?

Rana: In this story, each individual describes the animal based on the part of the elephant they feel, and may be unwilling or unable to accept another perspective. It is not so dissimilar for nail disease.

Take, for example, onychomycosis. This can be treated with antifungals with variable degrees of efficacy. But when it keeps on recurring, what next? This is where approaches can differ. For example, a primary physician might see the role of diabetes and tighten glucose control; a podiatrist may see the role of pincer nails and evaluate for underlying bony deformities; a dermatologist might evaluate for other causes of nail dystrophy such as psoriasis and attribute it to high recurrence rates of antifungal therapy.

It is important to consider all of these factors and more, but in reality only a small number of these potential contributors may be addressed depending on what we know and are comfortable with, which is ultimately a disservice to our patients.

What are your key conclusions?

Rana: The key takeaway is that nail health and disease are not as algorithmic as we would like them to be.

Many different factors (joint disease, nerve pathology, immune status, vascular integrity, occupation, infection) can affect nails -- and importantly, these factors often coexist. We need to be able to recognize these contributors and treat when able.

It is better to have honest conversations with patients than attempt a futile treatment strategy (e.g., repeat courses of antifungals) that carries cost and other concerns.

In addition, it is important to recognize that cognitive biases can fail us in the care of patients with nail disease. Even as a physician who sees a disproportionate number of patients with nail disease, I have become aware over the years of how my training influences what I see and don't see. It has challenged and inspired me to learn from others, like Tracey, so I can put the whole picture together for the patient.

What can a dermatology practice do in the short-term to close existing care gaps?

Rana: I don't think there is a one-size-fits-all solution, but there are a few things that might help.

Consider scheduling separate patient visits for nail concerns. If a patient mentions a nail concern during a skin check, for example, it can be helpful to have them come back so you can take your time to fully focus on the nail issue. Nails are difficult, and in a busy practice it is easy for them to be an afterthought. This approach makes it transparent to patients that you care and want to address the issue.

Identify local podiatrists and hand surgeons who can help care for patients with nail disorders if there are certain diagnostics (biopsy) or procedures (phenol matrixectomy) your practice does not offer. Patients are often frustrated when they have to go to multiple providers, so vetting these providers in advance and knowing their skill sets may help.

Vlahovic: This article encourages podiatry and dermatology to collaborate and learn from each other in the nail disease space. The practice gaps that both of our professions have in this area would certainly benefit from cross-talk and cross-research. I have learned so much from attending and working on the , which is open to being a multi-specialty group.

What can the dermatology profession as a whole do in the long-term to rethink the approach to nail disorders?

Rana: Nail disease clearly matters to our patients, but it isn't clear that dermatologists feel well-equipped to diagnose and treat nail disorders.

As we mention in our article, there is an opportunity to rethink how we deliver this care to patients. For example, are there opportunities to construct multidisciplinary "nail clinics" that unite podiatrists, dermatologists, vascular specialists, and hand surgeons, among others?

Finally, it isn't clear why many dermatologists don't do nail surgery, but this may be an area for further exploration. Although this may not play a singular role, it is notable that reimbursement rates for nail procedures are generally not on par with other surgical procedures done by dermatologists. This may discourage trainees and practicing dermatologists from mastering this skill and lead to more delayed diagnoses, including nail unit melanoma.