309Indian Journal of Dermatology, Venereology, and Leprology | May-June 2012 | Vol 78 | Issue 3
How to cite this article: Madnani NA, Khan KJ. Nail cosmetics. Indian J Dermatol Venereol Leprol 2012;78:309-17.
Received: July, 2011. Accepted: Septembar, 2011. Source of Support: Nil. Conict of Interest: None declared.
The earliest use of nail coloring dates back to ancient
Egypt and China. The first nail polish was made from
egg white, flowers, and wax. Natural henna was also
used as a nail colorant. Specific colors like red, gold,
and silver were chosen for royalty, and the common
folk had to use lighter shades. In ancient China, gold
and silver represented royalty. While red and black
represented strength and boldness, pale colors denoted
feebleness. Artificial nails date back as far as 600 BC
to the Chou dynasty in China, where nails were made
from gold, silver, and precious stones.
Modern day nail polish was formulated in 1920 by the
Charles Revson Company, which today is known as
Revlon. They were inspired by the enamel paint used
on cars to formulate something similar for the nails.
The modern day nail polish became commercially
available in 1932.
WHAT IS AN ATTRACTIVE NAIL?
Attractiveness of a nail is a subjective phenomenon.
A nail is generally considered aesthetically pleasing
if it has:
1. A smooth glossy surface.
2. No overhanging or ragged cuticle.
3. A tip extending beyond the nail.
4. An oval contour to the nail plate.
5. A gentle curve when visualized from the side.
6. Translucency so that the pink nail bed is clearly
The beauty of the nail can be further enhanced using
various shades and colors of nail polish.
The most popular nail‑grooming procedure is known as
a manicure (for fingernails) and pedicure (for toenails).
STEPS OF A MANICURE/PEDICURE
Prior to applying the nail polish, the hands/feet and
nails undergo the following:
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Nina A. Madnani, Kaleem J. Khan
Department of Dermatology,
P.D. Hinduja Hospital and
MRC, Veer Savarkar Marg,
Mahim, Mumbai, India
Address for correspondence:
Dr. Nina A. Madnani,
Department of Dermatology,
P.D. Hinduja Hospital and
MRC, Mumbai, India.
The nail as an anatomic structure protects the terminal phalanx of the digit from injury.
Historically, it has served as a tool for protection and for survival. As civilizations developed,
it attained the additional function of adornment. Nail beautication is a big industry today,
with various nail cosmetics available, ranging from nail hardeners, polishes, extensions,
articial/sculpted nails, and nail decorations. Adverse events may occur either during the
nail-grooming procedure or as a reaction to the individual components of the nail cosmetics.
This holds true for both the client and the nail technician. Typically, any of the procedures
involves several steps and a series of products. Separate “nail-bars” have been set up
dedicated to serve women and men interested in nail beautication. This article attempts
to comprehensively inform and educate the dermatologist on the services offered, the
products used, and the possible/potential adverse effects related to nail-grooming and
Key words: Acrylic nail, gel nail, manicure, nail polish, sculptured nail
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Indian Journal of Dermatology, Venereology, and Leprology | May-June 2012 | Vol 78 | Issue 3310
1. The previous polish is cleaned off with
a chemical remover and the nails are cut
to the required length with nail cutters or
2. The hands/feet are soaked in warm water with
a mild detergent to soften the nail plate and
cuticle and to remove any dirt or grease from
3. A foot scraper or a pumice stone is used to buff
away any rough skin or thick callus.
4. A cuticle softener (alkaline substances like 0.4%
sodium and potassium hydroxide) is applied
to the cuticles for 5–10 min. They dissolve the
di‑sulfide keratin bridges.
5. The cuticle is pushed back with a specially
designed metallic or wooden stick, and then
trimmed off with a cuticle cutter.
6. The surface of the nail is buffed with an emery
board to smoothen any ridges.
7. The hands/feet are rinsed and dried, and an
emollient cream is massaged to soften the skin
and trap moisture into the nail plate.
8. The cream is cleaned off from the nail plate.
Now, the nails are considered suitable for nail polish
The ideal nail polish application procedure includes
1. Base coat: This is the first layer to be applied. It
is transparent with a strong adhering capability
due to higher resin content. It protects the nail
plate from staining.
2. Nail polish: A plethora of colors are available,
with or without a metallic finish. The
expertise of the nail technician provides
various styles of nail polish application, of
which the “French nail manicure” is very
3. Top coat: This transparent layer contains more
of nitrocellulose and less resin, so as to protect
the varnish from chipping.
Each product is applied consecutively with a 10‑min
gap in between applications [Figure 1].
Nail polish serves the purpose of:
2. Strengthening weak brittle nails.
3. Camouflaging surface irregularities or
discolorations. It can provide a youthful
appearance to aged ridged nails.
Nail polish is a complex combination of:
1. Film‑forming agents (most commonly,
2. Resins (e.g., tosylamide–formaldehyde) for
3. Plasticizers (e.g., dibutyl pthalate) for flexibility.
4. Solvents (butyl stearate and acetate compounds)
for keeping the polish in fluid state and to help
in quick‑drying once applied.
5. Thixotropic agents (e.g., bentonite) for keeping
the ingredients uniformly suspended.
6. Various mineral pigments (calcium carbonate, zinc
oxide, titanium dioxide, iron oxides), synthetic
pigments (D and C red 6/7/19, FDC yellow).
7. Natural agents (guanine, bismuth, oxychloride,
and micatitanium) for the color and shine of
the nail polish.
HYPOALLERGENIC NAIL POLISH
The most common allergen in nail polish is tosylamide
formaldehyde resin (TSFR). Because of growing
awareness, “toxin‑free” nail polish is getting popular.
This variety contains cellulose, acetate, butyrate, and
polyester resin, with plasticizers such as dibutyl
phthalate for softness and pliability, dissolved in
solvents (N‑butyl acetate or ethyl acetate). Some
manufacturers claim to have “toxic‑free nail polish,”
which is free of toluene, pthalate, and formaldehyde
and contains natural pigments in a water base. Argan
oil, which has a high content of amino acids, has also
been used as an important ingredient.
These are applied as a base coat for the purpose of
strengthening the nail plate. They may contain titanium–
silicone–zirconium polymers, polytef, nylon, calcium,
and biotin. Those containing formaldehyde may cause
paronychia and irritant dermatitis, and are not in common
use anymore. Nail hardeners need to be cleaned off every
2–3 days to prevent onycholysis and chromonychia.
NAIL POLISH REMOVER
With the innumerable color choices available, nail
polish is constantly changed to suit women’s moods
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and clothes. This involves cleaning off the existing one
with removers. The following varieties are available:
1. Acetone – the most commonly available. It has
been reported to cause an irritant dermatitis.
2. Acetone‑free nail polish removers containing
ethyl acetate, butyl acetate, or ethyl lactate.
3. Nail polish remover pads containing
gammabutyrolactone, which are safe and
convenient to use. Rarely they get converted
to GHB (gamma‑hydroxybutyrate) resulting in
FRENCH NAIL MANICURE
This method is used to provide a “natural” appearance
to the nail. A pink color is applied to the main nail
plate, while a white color is applied to the free edge,
simulating a natural un‑painted nail, picturing good
health [Figure 2].
1. The cosmetic appeal of nail polish can be
enhanced with the application of ready‑use
plastic or metal artifacts immediately before the
2. The design pieces are skillfully lifted from a
template with forceps and placed on the freshly
applied wet nail polish, in a planned pattern
[Figure 3a and b].
3. This is then covered by a top coat, which
prevents it from getting dislodged.
4. Nail design can also be made, allowing the
first layer of color polish to dry completely
and subsequently painting a second contrasting
color on top of the first, with a design template.
Artificial nails evolved from the need for lengthening
or reinforcing soft, brittle, or damaged nails. These can
be partially attached as nail tips or used to reinforce the
entire length as sculpted nails (acrylic or gel based).
Ready‑to‑use plastic plates, shaped like nail tips are
available at nail salons. These are glued to the free edge
of the nails with adhesives containing methacrylate or
ethyl 2‑cyanoacrylate. The nail surface is filed roughly
prior to gluing the nail tip, in order to improve adhesion.
The glued‑on tips are then painted or decorated with
nail art and finally coated with acrylic or gel [Figure 4a
and b]. Entire plastic nails can be stuck on. The tips
can be removed with acetone.
These are either acrylic or gel based and are sculpted
over the existing un‑aesthetic nail. Both acrylic or
gel‑based nails involve a mix of a powder and a solution,
applied to the nail. A disposable foil with a printed grid
is used as a template for the application of materials.
A few drops of ethyl methacrylate mixed with powdered
poly‑methacrylate results in a polymerized mixture
that needs to be applied quickly due to the instant
setting potential. A uniformly thin layer is applied
to achieve the desired effect. The powder contains
benzyl peroxide, which acts as a catalyst, while
hydroquinone acts as an inhibitor of polymerization.
Individual brands may add titanium dioxide and
permitted colors. A further modification of the process
is the gluing of pieces of silk, linen, or fiber glass to the
nail, prior to the acrylic application. These are called
“nail wraps” and add strength to the nails. Acrylic
nails can be removed with acetone.
The powder and the liquid phase of gels is akin to dental
resin and requires specific UV‑light exposure to set
and cure (harden) the gel after application on the nail.
These nails appear glossy, are aesthetically appealing,
have greater strength for endurance to physical wear
and tear, and need less after‑care [Figure 5]. Gel nails
can be removed only by completely buffing them off
the nail plate. This results in physical damage to the
nail plate during each removal. “Touch‑up” procedures
are required for both acrylic and gel nails. As the
nail plate grows, a gap appears at the proximal end
between the nail fold and the artificial nail [Figure 6]
that needs to be filled up at regular intervals, usually
every 2–3 weeks.
These can be broadly categorized as those due to
the chemical components or complications during
or subsequent to the nail‑grooming procedure. Most
reported adverse reactions due to the chemical
components have been tabulated in Table 1.
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Procedural complications of a manicure/pedicure
These may occur in the periungual tissue, the nail plate,
or at distant sites due to an allergic contact dermatitis.
1. Cuticular cuts and “hang” nails are common
with the cuticle‑trimming procedure and can be
2. Irritant reactions or chemical burns following
use of the cuticle softener are usually seen
around the proximal paronychial fold.
3. Clipping nails when dry can cause
onychoschizia, with horizontal splitting of the
nail plate in layers, making it brittle.
Figure 2: French Manicure – It stems from the idea of a healthy
nail where the free edge of the nail is bright white and the proximal
nail has a pink hue
Figure 1: Bright‑colored nail polish adds to the beauty of the hand
Figure 3: (a and b) Nail adornment
Figure 4: (a and b) Nail art – Decorative art along with sparkles add to the nal effect of the nail
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4. Over‑zealous buffing of the nail plate can thin
the nail plate and cause fragility.
5. Paronychias, bacterial, fungal, and viral
infections, especially verrucae, can be
inoculated or spread between patients with the
use of non‑sterile implements.
6. Pedicure tubs in which hands and feet
are soaked have been reported to cause
Mycobacterium fortuitum infections from a nail
salon in California.
The physical process of nail beautification has its own
set of adverse events, as have been enumerated earlier.
Softening/pushing back/cutting of the cuticle, in nail
parlance, is a very important step. Anatomically,
the cuticle has a very important role in sealing the
potential dead space below the proximal nail fold.
A damaged cuticle exposes this walled‑off space to
external agents like detergents and bacterial, viral, and
fungal pathogens. Subsequently, acute‑over‑chronic
paronychia ensues, which, over time, results in nail
dystrophy. Cuticle softeners contain alkaline chemicals
that cause an irritant dermatitis. Dombrowski and
Llyod reported a case of chemical damage to the cuticle
and nail plate by application of a callus remover
instead of a cuticle softener, under occlusion, resulting
in arrest of cuticle formation.
Separation of the nail plate from the nail bed can result
from over‑zealous clipping of the hyponychium or as
a consequence of a “lever effect” following minimal
trauma, especially in long “strengthened” sculpted nails.
Hapalonychia, the thinning of the nail plate
postbuffing, results in weak foldable nails.
Onychoshizia may be attributed to faulty trimming
when the nails are dry, leading to horizontal layering
of the nail plate.
Repeated use of nail polish, especially deep colors like
red, often stain the nail plate. Staining was reproduced
with D and C red no 7, D and C red no 34, D and C red
no 6 and FD and C yellow no 5 lake. The likelihood of
staining increases if the pigments are dissolved and
not suspended [Figure 7].
Patients may develop delayed hypersensitivity
reactions around the painted nail and rarely present
with acute contact dermatitis. Allergic contact
dermatitis from nail polishes has been seen to
affect distant sites like face and neck commonly,
especially on the eyelids and around the mouth.
Unusual involvement of other distant sites like the
genitals and perianal region have also been reported.
TSFR was the seventh most common ingredient causing
contact dermatitis in patients with a cosmetic allergy.
Baran described surface friability of the nail plate,
mimicking a white superficial onychomycosis,
following the use of nail products [Figure 8]. The
keratin granulations occurred more commonly when
Table 1: List of reported adverse reactions to individual
constituents of nail cosmetics
Nail cosmetic Component Reported side-effect(s)
Nail polish Nitrocellulose Allergiccontact dermatitis
Formaldehyde Allergiccontact dermatitis
Dibutylphthalate Allergic contactdermatitis
Butylstearate Contact dermatitis
Dand Cyellow 11 Allergiccontactchelitis
Acutetoxicity in9 and15
Nail adhesive Methylacrylate Skin sensitizer
Ethyl2- cyanoacrylate Allergiccontact dermatitis
Acrylicnails Methacrylate paresthesia
Benzoylperoxide Allergic contactdermatitis
Gelnails UV light Nonmelanomaskin cancer
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the nail polish was kept on for several months or when
it was re‑applied without removing the first coat and
also when a primer base coat was not applied.
Nickel‑sensitive patients may develop an allergic
contact dermatiis due to the adornments. In such
patients, adornments chosen may be of gold or may be
RELEVANCE OF NAIL COSMETICS IN A HEALTHCARE
Long fingernails harbor bacteria, and antimicrobial
soaps/gels may not be sufficient for complete
elimination. Long nails are cumbersome, reduce grip,
and tend to puncture gloves. Hence, they are best
avoided by medical professional in healthcare settings.
Wynd et al. in their study on 102 perioperative nurses
concluded that chipped nail polish or nail polish
worn for more than 4 days increased bacteria on
fingernails. Opaque nail polish can mask nail signs
during a clinical examination. The possible role of nail
varnish in altering pulse oximeter reading has long
been debated. However, it has now conclusively been
seen that there is no effect in the measurements from
healthy or hypoxic subjects. Chan et al. suggest placing
the probe in a side‑to‑side position on the finger to
preclude any disparity in the measurements.
NAIL COSMETICS IN NAIL DISEASE
Many dermatological diseases cause disfigurement of
the nail plate, which may be cosmetically unacceptable
to the patient and reduce his or her quality of life.
The duration of treatment for most intractable nail
disorders is long, with poor efficacy. While waiting for
the therapeutic response, cosmetic camouflage helps
Figure 7: Prominent staining of nail plate along with onycholysis
results from regular and repeated use of nail polish and nail
Figure 8: Keratin granules simulating supercial onychomycosis
Figure 5: Gel nails – These look similar to acrylic nails but are
stronger and appear more glossy
Figure 6: Development of a clear area at the proximal nail fold as
the nail grows out. Note also the onycholysis in the little nger
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the patients tide over the mental discomfort. Nail
polish application may be adequate for camouflaging
dyschromias and mild dystrophies. Gel or acrylic nails
may be helpful in concealing moderate nail dystrophy.
For cases of anonychia or severe nail dystrophy, a nail
prosthesis may be the only option. This prosthesis
consists of a false nail attached to a silicone finger
glove molded to the specifications of the corresponding
finger of the opposite hand.
NAIL COSMETICS IN CHILDREN
Nail cosmetics are generally not recommended for use
in children. However, the author has seen mothers
using it on their children’s nails in order to break the
nail‑biting habit, the deterrent being the taste. This
is not advisable, as there is always a possibility to
develop adverse reactions.
OCCUPATIONAL HAZARDS FOR NAIL TECHNICIANS
Nail technicians are at a risk of occupational hazards
due to constant exposure to chemicals used for
various nail cosmetic procedures. Increasing number
of technicians are sensitized to acrylate monomers
used on sculpted nails. Some are at risk for developing
occupational asthma due to the cyanoacrylates
used. McNary and Jackson concluded in their study
that neither nail technicians nor consumers are at any
additional risk when exposed to formaldehyde and
toulene at their work place compared with exposure
from commercial products at home.
UNUSUAL ADVERSE EFFECTS
Nail polish remover pads were reported to have caused
bilateral pneumothoraces, pneumomediastinum,
and respiratory obstruction in a 15‑month‑old child
who accidently sucked on them. Fortunately, with
medical treatment, the child recovered completely.
Turgut et al. reported a case of bacterial endocarditis
developing as a consequence of a pedicure. A series
of patients developing candidal osteomyelitis and
diskitis, narrowed down to a nurse who was wearing
artificial nails, was reported by Parry et al.
TESTING FOR ADVERSE REACTIONS TO NAIL COSMETICS
1. Nail polish should be tested as it is.
2. A specific resin can be tested in 10% petrolatum.
3. Nail acrylate allergy should be tested with
2‑hydroxy methacrylate, ethyl cyanoacrylate,
and methyl methacrylate monomer 10% in olive
4. Patch testing for nail polish removers should be
an open patch test, at a concentration of 10%,
dissolved in olive oil.
5. Cuticle removers tested as a 2% aqueous
concentration as an open patch test.
TIPS TO PROVIDE TO PATIENTS VISITING A NAIL SALON
1. The nail salon should have a clean environment.
2. The nail technicians should be neatly attired
and have clean nails.
3. Check how the nail implements are cleaned
and sterilized. Implements like nail clippers,
nail cutters, foot scrapers, callus removers, and
electric drills are sterilized best with autoclaving
or soaking in 7.5% stabilized hydrogen peroxide
for 6 h or in >2.4% gluteraldehyde‑based
formulations for 10 h to remove all pathogenic
organisms and spores. The trend at the parlors
is to soak the instruments for 10 min in
disinfectants like benzalkonium chloride.
These may still harbor bacteria, fungi, yeast,
4. Carrying one’s own implements is a wise
5. Nails should be cut only after soaking for 10–
20 min in water to prevent onychoschizia.
6. Over‑zealous pushing back the cuticle or
nipping the cuticle by the technician should
be avoided, as it leads to infection and
inflammation of the nail folds.
7. Nail polish should be left on for few days only,
and cleaned off with acetone‑free cleansers.
Nail hardeners too need to be cleaned off every
2–3 days. Inform the patient about the probable
staining effect of dark nail polish. Avoid layering
on nail polish without cleaning off the old one.
8. Inform the patients about nail plate damage
with application of artificial nails.
9. Any swelling, pain, redness, and growths
around the nails should be attended to by a
Although nail cosmetics are advantageous for
“beautifying” or concealing various nail disorders,
adverse effects are a definite possibility. As
dermatologists, a complete knowledge of various
Madnani and Khan Nail cosmetics
Indian Journal of Dermatology, Venereology, and Leprology | May-June 2012 | Vol 78 | Issue 3316
nail products, nail‑enhancement procedures, and
anticipated complications and their management can
result in better patient care.
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