Background. Conservative treatment of secondary recurrent unguis incarnatus are not very effective and

The aim of research is optimal sequence of surgical treatment, local and system therapy after moving away of the staggered nails at destructive onychomycosis, complicated by the secondary ingrown nail for some patients with the complicated mycotic defeat of nails. Materials and methods. Over a fi

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Causes of unsatisfactory outcomes of ingrown nail and mycotical pathology complex treatment were insufficiently studied for approaches to preventing relapses. The need for complex research on surgical nail pathology is primarly determined by a large number of clinical observations of uncomplicated and complicated cases, especially relapses. The mycotic paronychia and the chronic subungual abscess are compressed along the nail edge. Not all surgical procedures that have been successfully treated paronychia you can apply for the correction of ingrown nail. Late compression relapses with monoonychocryptosis are 5–18 %, and with ingrown nail combined with onychomycosis – 30–70 %, which is also confirmed by our previous studies. Fungal infections of the nails (onychomycosis) in combination with ingrowth remain one of the most serious problems of dermatology and dermatological surgery. In domestic literature there is a significant number of works devoted to pathology of the nail plate, however, the surgical aspects of the onychology are assigned a minimal, secondary role.The aim of the study – optimal sequence of surgical treatment, local and system antimycotic therapy, clinical and biochemical parallels after moving away of the incarnated nails at trichophytosis and destructive polyonychomycosis, complicated by the secondary ingrown nail for some patients with the complicated defeat of nails.Materials and Methods. Over a five-year period 436 unguis incarnates diagnosis (among them 325 cases of incarnated multifocal mycotical-assotiated nail pathology – the main group, included sub-selections of patients with diabetes mellitus and metabolic syndrome) in 259 men and 177 women 28–86 years old were performed. Adequate system therapy of patients with comorbid diabetes mellitus and metabolic syndrome was carried out. In 182 patients late relapses of onychocryptosis were confirmed after previous surgeries at other clinics. Conservative treatment was recommended only at early stages of ingrowth. Removal of the affected nails was performed in patients with mycotic lesions (local and systemic fungicide therapies were used). Investigation of the morphogenesis of destructive aspect of the mycotic lesions was carried out. The analysis justifies the feasibility of establishing predictive relationships between clinical variants of chronic purulent necrotic infections and combined comorbidity.Results and Discussion. 363 cases of destructive purulent-necrotic superficial chronic, combined and combined lesions of the distal phalange of the toes with nail plate ingrowth were studied in patients aged 12–75 years, 236 men and 127 women operated in surgical departments were investigated. All surgical procedures are performed correctly according to local protocols. Nosological forms of lesions are associated with some degree of onychocryptosis, according to the dominant clinical manifestations of ICD 10 were divided into sub-samples – actually onychocryptosis, dermatophytosis and candidal onychomycosis with incarnation of the nail. Other 73 patients with uncomplicated mycosis some conservative treatment were performed correctly according to local protocols. Analysis of subonychial scraping allowed stating the prevalence of red trichophytia, where in 74 % of cases it was associated with mold, in 26 % cases it was associated with yeast fungi; and in 31 % cases – with the bacterial flora; applied 4 "pulses" of itraconazole 400 mg/day. We studied some indicators in the lipid profile, which were significantly higher in both groups of patients, p <0.01 for both groups; noted the positive correlation between the level of total cholesterol and leptin (p <0.01). The concentration of high-density lipoprotein cholesterol in patients of the main group – (5.2±0.1) mmol/L compared with patients in control group – (2.8±0.2) mmol/L. The average content of nitrogen oxide in the study group (metabolic syndrome) was higher than that in healthy patients – (15.1±0.9) mcmol/L, p <0.05. Patients of the main and the comparison groups with type 2 diabetes mellitus with ingrown polyonychomycosisexperienced considerable decreasing HOMA -index of β-cells function and increasing HOMA -index of insulin resistance (8.11±1.1) in the main group and (2.2±1.2) in the control group). The late unsatisfactory results of the complex treatment of destructive onychomycosis associated with incarnation (occurrence of compression relapses) are determined by the technical errors of the operation interventions (inadequate selection of the method and volume of resection, traumatic performance of onychectomy, failure to perform partial matrixectomy), disregard of pathogenetic and morphogenetic factors of destructive onychomycosis, the refusal to perform simultaneous surgical interventions on deeply placed structures in case of combined mycotic-associated lesions, ineffective pre- and intraoperative prophylactic actions to prevent spreading mycotic infection to deeply placed structures.Conclusions. In all cases of mycotic onychocryptosis (secondary ingrown toenail) underwent a comprehensive treatment of comorbid pathology, system therapy of itraconazole to operative treatment (basic onychial defeats sanation) and in a postoperative period was carried out, some patients with combined pathology got 4 seven-day system "pulses" of 400 mg/day itraconazole therapy. Sanation of other nails for prevention of mycotic reinfection was carried out by ciclopirox or amorolfine lacquer. We recommend using more radical and effective three-component surgical methods: nail resection or removal of the nail plate, supplemented by excision of pathologically altered eponycheal tissues and partial marginal matrixectomy in the area of ingrowth. In patients, the low-impact methods of excision of the nail and partial marginal matricectomy by mechanical carving and coagulation with the further dermatophytoma scraping off with the Volkmann spoon were embedded and applied.

In the pathogenesis of chronic infectious fungal processes, an important role is determined by the weakening of the body's protective factors. There are "endogenous and exogenous factors" that contribute to the transformation of fungi from vegetation to pathogenic. Endogenous factors (age, general infections, metabolic diseases, hypo- and avitaminosis, metabolic syndrome, gastrointestinal diseases, neuropathy) are define some clinical variants. Destructive fungal lesions predominate in middle-aged and elderly people, in elderly patients "surgical nail pathology" is half of all observations of purulent-necrotic chronic lesions of the distal parts of the hand and foot. The purpose of the work was to introduce minimally invasive nail removal or resection of nails by block-shaped eponychectomy access with the use of pedicure instruments, study of biochemical changes in the background of pathology, detection of correlations between hypo- and avitaminosis with the development of destructive onychomycosis. It has been established that conservative, podiatric and orthopedic treatment of mycotic surgical lesions and secondary nail incarnation are not very effective, while some classical methods are Dupuytren's nail removal, Emmert-Schmiden operation and others in 2-20% of cases (depending on the absence or presence of onychocryptosis and associated fungal lesions) determine recurrences. Instead, the proposed low-trauma removal or resection of nails by block-shaped eponychectomy access using pedicure instruments, excision of dermatophytoma with partial marginal matrixectomy, which significantly reduces the number of recurrences of ingrowth (respectively 1-3% in the early stages and, 3,25% та 6,42% periods of growth, χ2 = 28,17, p<0,01) and determines the improvement of quality of life. The study of endothelial function revealed the presence of endothelial dysfunction in most patients, which confirms our previous studies and literature data. Blood lipid spectrum  was significantly higher in both groups of patients (main and comparison group), compared with almost healthy individuals (p<0.01 for both groups, compared with controls), which is consistent with the literature. It was found that the supply of vitamins B1, B2, PP, B6 and C directly correlated with the severity of the underlying disease. In patients with polyonychomycosis with significant symptoms of background polyhypovitaminosis, some purulent complications of mycotic onychodestruction were detected – subungual abscess / panaritium, complicated nail incarnation  and mycotic-associated paronychia with purulent onychia / onycholysis of more than three nail plates. For comparison, in the other half of the sample of persons with less pronounced symptoms of polyhypovitaminosis, some purulent complications were found in only 37.5% of the subsample, which suggests that there is a relationship between the manifestations of multivitamin deficiency and the severity of necrotic complications. Low-traumatic mobilization of the nail through a block-like eponihectomy and nail plates removal or resection (some nail incarnation) of through areas of onycholysis/onychomadesis, or resection of nails through hyperkeratosis / onycholized structures using our methods, according to our complex analysis, due to reduction of intraoperative injury, determines increasing the rate of wound healing (χ2=32,14, p<0,01) and statistically significant minimization of the risk of mixed and reinfection of adjacent anatomical structures.