Keys To Advising Patients On ‘Safer’ Pedicures

My patients and former students know my stance on pedicures. I am not a fan due to seeing infections resulting from unsafe pedicure practices almost every week I have been in practice. I have treated everything from onychomycosis to periungual verruca to a patient almost losing her digit from a bacterial infection following a pedicure. In order to understand the potential complications following this service, it is important we review the protocol of a pedicure and the tips we can offer patients to have a “safer” pedicure.

First, pedicurists remove any nail polish with nail polish remover. Then they soften the nails and cuticles with a soak or a foot bath. Pedicurists clean the hyponychium (where the nail and the skin meet distally) with a metal device or orange stick to loosen any debris. Then the pedicurist removes or “pushes back” the cuticle with various instruments. If nails are stained, pedicurists may apply a bleaching agent such as hydrogen peroxide and if there is any ridging on the nail plate, the pedicurist may buff the nail. After shaping the nails with a nail file, the pedicurist applies base coat, nail polish, and a top coat followed by a spray or another product to facilitate the drying-time process.¹

The hyponychium and true cuticle (the colorless and sticky structure on the dorsal surface of the nail plate) are waterproof barriers that seal the nail unit from infection and the outside world.¹ Disrupting those barriers can create a paronychia (defined simply as inflammation of the periungual region, not as an infected ingrown nail), onycholysis (separation of the nail plate and nail bed), and introduce invasion from bacteria, fungi or viruses.

Onycholysis, often visible as a whitish discoloration at the distal edge of the nail plate following a salon nail service, creates a small pocket of dead space that can become colonized by bacteria, fungus or yeast. If Pseudomonas is the culprit, the nail will appear greenish. However, if a dermatophyte such as Trichophyton rubrum has taken hold of the area, then the yellowish-brown discoloration associated with onychomycosis may be potentially be visible.

In addition to these pathogens taking advantage of spaces created by the sharp instruments in a pedicure, infection from the multi-use instruments (nail clippers, cuticle nippers, drills) is a widespread and dangerous side effect of having a manicure/pedicure.¹

The Centers for Disease Control and Prevention (CDC) considers these instruments to be “critical items” or implements that enter sterile tissue or the vascular system. Critical items are associated with a high risk of infection if contaminated and one should autoclave them. However, liquid immersion in chemicals is also an alternative to rid the instruments of spores from bacteria and fungus. This includes immersing the critical items in hydrogen peroxide for six hours and glutaraldehyde for 10 hours.

However, following these protocols is the exception and not the rule for most salons due to the fast turnaround times they have with clients. Most salons only immerse the instruments in a disinfectant (like chlorine or quaternary ammonium) for 10 minutes between customers. There are not enough state inspectors to monitor the enormous and ever-changing numbers of salons in the U.S. to determine if salons are following sanitation guidelines.² 

So what should our patients do if they want this salon service? I understand telling patients to avoid pedicures at all costs is unpopular and not realistic. Due to the risk of developing a fungal, viral and/or bacterial infection, I do recommend patients avoid manipulation of the hyponychium and true cuticle during their pedicure (i.e., tell the technician to not push back the cuticle and scrape underneath the nail). I encourage them just to have their nails filed and polished. Some patients even prefer to bring their own nail polish to avoid contamination with polish from other customers. I ask patients to look for a salon that has disposable liners for the water basin in a pipeless pedicure chair or just not utilize a foot bath at all.  

What are some other tips we can give patients? According to the American Academy of Dermatology, we can recommend the patient examine the cleanliness of the salon, technician (i.e., are pedicurists washing their hands in between clients?) and instruments at the technician’s station.^3,4 Don’t hesitate to ask how pedicurists clean the instruments.

Patients should shave their legs 24 hours or more after having a pedicure service. If they shave their legs before, they risk developing an infection in the hair follicles (bacterial or fungal) once they are exposed to the foot bath. Adding a chemical to the foot bath to “disinfect” it without routinely monitoring/changing the filters is not enough as the filter can have bacteria attached to it. One study identified Mycobacterium fortuitum as the cause for boil formation in 70 percent of the clients who shaved prior to their pedicure and then had exposure to the foot bath.⁵ Again, I recommend using a single-use liner in a foot bath or using no foot bath at all. 

If patients choose to wear a red or orange nail polish, do keep in mind that it can stain the nails yellow for several weeks. Patients (and some doctors) may mistake this yellow discoloration for nail fungus when in reality, it is surface staining that will disappear in a few weeks. A base coat can assist in lessening the staining. 

Many doctors recommend patients purchase their own instruments to keep at the salon or bring back and forth with them. There are two sides to this: patients have instruments that no one else can use, which is obviously beneficial. On the downside, patients also can keep reinfecting themselves with their own nail fungus (if present) since they are not properly disinfecting instruments in between visits. In this case, I truly prefer patients to have the nails filed and polished, and avoid any instrument that is going to cause harm to the cuticle or hyponychium. 

In an entrepreneurial spirit, many physicians are opening up medical-based pedicure salons adjacent to or as an included space in their practices. Employing nail technicians and using autoclaved instruments, these “medi-pedi” services have a physician on the premises and may be as pampering as a salon visit. They provide a safer alternative for those who should avoid or be wary of receiving a general pedicure. These patients include patients with diabetes, immunocompromised patients, patients on blood thinners, etc. 

References 

1. Dahdah MJ, Scher RK. Nail diseases related to nail cosmetics. Derm Clinics. 2006; 24(2):233-239. 
2. Rich P. Nail cosmetics. Dermatol Clin. 2006; 24(3):393-399. 
3. American Academy of Dermatology. Manicure and pedicure safety. Available at https://www.aad.org/public/skin-hair-nails/nail-care/manicure-safety.
4. United States Environmental Protection Agency. Recommended cleaning and disinfection procedures for foot spa basins in salons. Available at https://www.epa.gov/pesticides/recommended-cleaning-and-disinfection-procedures-foot-spa-basins-salons.
5. Winthrop KL, Abrams M, Yakrus M, Schwartz I, Ely J, Gillies D, Vugia DJ. An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon. N Engl J Med. 2002;346(18):1366-71.