Review and Therapeutic Approach to Malalignment of the Great Toenails: A Common Condition That Is Uncommonly Diagnosed.

Hello and welcome to episode 47 of our Clippings podcast where we review nail papers and we share them with you. I'm April Shaq Tehl and I'm joined today by my co-host who I will let introduce herself. Andrew Zabblerana, hi there. And Jasmine, can you introduce our listeners to our guests for today? Absolutely. I am so so excited for this episode and we have with us today to amazing most surgeons, Dr. Julia Balts and Dr. Nat Gelenik. They practice in Rhode Island and we're so so lucky to have them chat with us today about one of the new papers that they published. I love the title about this. By the way, it's called Review and Therapeutic Approach to Malalignment of the Great Tonials, a common condition that is uncommonly diagnosed and Dr. Zabblerana Gelenik publishes article with Dr. Porter, Hannah Porter and Dr. Bertrand Recher. And I should mention they are national probably international experts in nail disorders, especially when it comes to nail surgery. And so this is really a true treat for us. So thank you both for being on today. Nice. We were going for the longest title we could get in this edition of Dermsaries. We had a few other sentences. Paired it down. Collin, semicolon. And I wanted to say too, I love that you guys are doing this podcast. I'm blown away that it's already number 47, which is amazing. And I'm thinking about like number 50 should be huge, number 100 should be huge. It's great. It's an incredible educational opportunity for all of us. So thank you. Thank you so much. Yeah, I know we're so so happy to be doing this. And yeah, happy to learn from both of you today. And curious of maybe for our listeners, you could kind of give us a sense kind of how you integrate nail disorders into your practice, kind of what your clinical day to day is like. And then what inspired you to write this paper in particular? Yeah, so both of us run a dedicated nail clinic once a week. So it's one half day clinic per week in which we see any and all nails. So while we are both fellowship trained most surgeons are feeling I say, I'm speaking for that, but I think we think about this the same is that you have to see everything to really be a great diagnostician and you know, a great surgeon. And so we are treating onachomycosis. We're treating care with rinicky as a rise is like in planus. And then we're also doing you know, most surgery for skin cancer and melanoma surgery. So really running the gamut. And for me, what inspired us to write this paper was that we see malalignment every single week in our clinic. There isn't a clinic that goes by right. I don't have a patient who shows up and they say, I've had issues with my nails for the past 30 years. I've had fungus. I can't get rid of this. And nobody's been able to help me. And it's something where I tell my medical assistants, I already know what it is, but we're going to let them get it out even though this could be a 22nd visit. We're going to give them their time to talk about it. So we just want other clinicians to be able to recognize it. So these patients aren't erroneously treated for years on end. Yeah, I mean, I think going back to the first point too, the adding diversity into your week, even though the nail clinics are not easy, their hard clinics because patients tend to be frustrated. You're the, you know, last person that's going to help them like last great hope, which is a lot of pressure. And I always try to diffuse that because sometimes, you know, it's a 40 year problem and you're not going to fix it. But so I think that they can be actually emotionally difficult clinics, but very rewarding. And it mixes it up enough for us that we're not just doing the same thing over and over again with skin cancer. And it makes you think medically, which is, you know, you have to keep your finger in the pulse of inflammatory diseases and, you know, topical medications and all the rest of it. So I like how it fits into our clinic. And I also like that, you know, for the two of us who do surgery most of the time, it does lend itself towards the finer procedures on the nail unit that I think are intimidating and has helped us think outside of the box in some of those nail procedures. Yeah, no, I think to your point about, you know, this emotionally difficult nature of the nail clinic, I think patients are even just happy when you can give them a diagnosis, right? Like even if you can't fix it. And I think that was something that I had the perhaps amazing privilege of seeing firsthand when I came to visit both of you in rural islands. That was very cool to see. And I think maybe for listeners, could you define kind of what malalignment is and what is the current understanding of what causes it? Right. So malalignment I think can be defined as the a nail where the longitudinal axis of the nail is not parallel to the longitudinal axis of the terminal phalanx. And so usually that's on the big toe, usually it's laterally malaligned. But you can have a medial malalignment and you can see it on other digits. And often on the big toe, it co-exist with an actual joint malalignment, the the halux valgus interfound gs. But you also have this nail malalignment. And so things just aren't parallel the way they should be there. And there are, we detailed this in the paper, three general lies, sort of a three clumps of etiologies. So I think the simplest to understand and not the so the most common would be an ayatrogenic one where you remove a wedge on one side of the nail. And the nail actually grows towards that side as if there isn't pressure coming from either the matrix or the nail folder or whatever anymore. And that can be a subtle and that can be dramatic. I mean, can we keep dramatic where you have a 45 degree malalignment and then sort of that becomes a secondary problem to be addressed. So that's like the easiest one to understand. It usually happens with wider lateral longitudinal excitions. They have tuberculosis paper quoted three millimeters. So wider than that. I mean, our lateral longitudinal excitions for inflammatory conditions are often one and a half millimeters. So we keep them fairly slender and don't see malalignment there. But wedges, big, wordy, tumor, most surgery, benign tumor, exige and super short equilibrium, so much type of thing can easily give you malalignment. And it should be consented for in that process. So I think that's the most easiest to understand. Other acquired cases would be either we see it in scarring like in planus. So I think it gives you a tridium. If it happens on one side of the nail, you can get malalignment towards that. So, and people with bad scarring LP, you can see that. And that's again, tridium and malalignment, they're both sort of not correctable at that point. And then something we see less often in derm, more often in hand in ERs and crush injuries, that can lead to malalignment. And the literature suggests that that's why you repair nail-bed lacerations. And the pearl there is that if someone has a hematoma from a crush and it's more than 50% of the nail bed, then you should get an x-ray and look for that and consider of ulcing the nail to at least look for laceration to repair. And then the most common and least well understood is the congenital malalignment. And you know, we don't usually diagnose these in neonates because the nail is normal, it's just the alignment isn't. And the kids normal, in almost every case, there are some syndrome associated ones, but mostly these are normal people, no problems at all. So they have a malalign nail, but the nail is normal. And so you're not chasing anything there. But the the deft clinician will be looking at neonates and see that there's malalignment in some of those babies. And as we'll talk about in a minute, you really don't see these patients presenting until they get the secondary signs of malalignment. But going back, they were almost certainly born with it. And when a patient finally makes it to you for this condition, what do you find that they typically complain of or what do they want treated? Yeah, so typically patients are looking for a phenotypicly normal looking nail. And I find most of them come in either having diagnosed themselves with or having been told that they have a fungal infection. So I've got this fungus. I can't get rid of it. I've tried xyz medications and it's still here. Always antifungals. Always. They monitor binephine. They've been doing topicals and it's just not going away. And then otherwise, I mean, there are some patients who have what I call terminal or end stage malalignment, where they have a completely dystrophic nail plate. These are usually more elderly male patients, I find if I'm stereotyping them in my clinic, who are coming in mainly just concerned that it is uncomfortable. And they just want to get rid of the nail. They don't really care why it's happening. They'd like to get rid of it. So those are the two different patient populations that I see. And I think there's a small group who presents with retranetia. And then we treat the retranetia, but most of the time I see retranetia, it's in the setting of a lateral malalignment. And then the recurrent onachymidesis, the boselines that you see, that of course, you onachymidesis into the ventral surface and the proximal nail fold, you get this retranetia. And so that's sort of like a backwards way into diagnosing and educating about the condition. That does seem like there is quite some overlap between the retranetia and the malalignment, like one leads to the other, and presumably. And curious, do you see a lot of patients in kind of the pediatric age group? Because you did mention, like, the late stage, like, you know, in theory, we should be seeing these patients earlier, but, you know, in practice, kind of what do you end up seeing? Yeah. I think we do. I see a lot of either young kids around that two to three age group, or 12 to 15 kids who are involved in dance sports, those types of things. And for the former, you know, you have parents who have this otherwise well child and they're very concerned, you know, is this something to be worried about and what do we do? And then for that second group, it is similar, but again, it's something where it's a new change in their kids' toes. The kid starts to be a kid, I guess the adolescent, the teenager starts to be very self-conscious about it. That's when I see that presenting in the pediatric age groups. Yeah. And I mean, I've seen it so stereotypical where it's like a toe-walking three-year-old, you know, and so they're telling you they've got the trauma, which is causing the secondary size. Yeah, that's really helpful. Yeah. I think it's a perfect segue to talk about treatment. And so it sounds like a lot of these factors kind of basically weigh into how you would approach treatment. So could you just walk us through kind of probably how you think about that and especially as surgeons, who is a good surgical candidate and who isn't? So it's a pretty dissatisfying diagnosis to treat because there isn't an easy cure, you know. I mean, with psoriasis, it's sort of a question of just how aggressive are you going to be? But most cases, if you're going to willing to go all the way, you can help people with psoriasis. Like in planus, we can help a lot of people, you know, not everyone. And I'm tortured by my difficulty to treat patients because they can be very challenging. But this is one where it's hard to get them back to normal, you know, especially if they present with a lot of secondary signs. So it's slightly more challenging because you're educating them and then you're saying, yeah, yeah, we can't help you. Which is actually one of the things just to offer, I never say we can't help you because these people have all have been heard heard from everyone else that we can't help you. So I actually do the opposite. Most of the cases, I say, even if I'm scratching my head, we can help you because they almost patients who are at the stage of seeing us on this call need to know that medicine is not giving up on them. So, you know, the key to this, like a lot of nail diseases, educating them. So they have to get what malamine is, how we defined it before. They have to understand that once the nail is malaligned, the connection is tenuous. And so recurrent microtrama will lead to thickening of the nail, ridging of the nail that dull oyster like appearance, onical lysis, eventually potentially onicogryphosis, disappearing nail bed, triangular shaped nail, you know, with contraction of the nail folds, et cetera. But it all comes from the fact that we're ambulatory creatures that live in a close box our feet do. And the, depending on our own biomechanics and our activity level, we're going to have more or less trauma to the big toe. So it's a lot of education about this is how we got there and sort of answering questions along the way they have them get buy-in to that's what it is, because as Julian mentioned, they all say I have a fungal infection. And we're going to address, you know, how do you address that question later, but whether you're a fungal infection or not, you have bad malalignment. So that's sort of like the take the point, you know, over and over again, and making sure they understand that. And then once they get that, you know, we always start with conservative measures. We'll trim back the nail to its proximal most detachment point and clinic, because we have the tools to do it without hurting. And they'll tell you usually that they can't do that at home. We strongly encourage them to maximize shoe fits. So, you know, no heels, wide toe box. I don't have people change their activities. I've had parents want their kids not to play soccer or tennis or hike. And I'm like, no, they have to do everything. Like your kids perfect, let them do everything. And let's like maximize shoe fit. I have sent people to podiatrists for orthotics to maximize support, minimize toe trauma. When kids are growing, you guys have kids, you know, as they get like new shoes every six months sometimes. So like having parents really pay attention to that. And those are the sort of easiest conservative measures we can use your radiators off in the nail so that they can trim it at home. Councilor, let's do it at the end of a shower or bath. I mean, all those things are good at keeping the nails short and preventing retronicia and sort of allowing them to fit into shoes without pain, but they're not cures for the condition. Yeah, so surgical options fall into two categories, right? There's corrective and then there is symptomatic surgical management. We think about corrected surgical management. The option for these patients is what we call realignment surgery, which is a rotation flap where you're essentially elevating all of the tissue off of the bone, including the matrix, and you're rotating that tissue so that it is aligned precisely with the terminal balance. And it's a very technically demanding surgery. It also carries risk for the patient. The main risk is you can, if you don't have good blood supply in your flap, you can get a schemic injury to the nail matrix. And potentially you could have death of the entire matrix and the no nail at all. And even the distal tip? Mm-hmm. It's a morbid procedure. It can be a high morbid procedure. And then the other part of that is the recovery. We would recommend at least a month of offloading. So, you know, we recommend this surgery in little kids before they reach the age at which they have the terminal or end stage changes. However, I think anyone with small kids can imagine trying to immobilize your four-year-old for a month would be a disaster. You might have to cast them, you know? Yeah, so it's tricky. So really finding the perfect candidate, right? Someone who doesn't have those end stage changes, they don't have a despairing nail bed sign, they don't have a fraction of the nail bed. And they are able to offload pressure and be really diligent about that for at least a month as they're recovering. Yes. So overall, we do not do this much. Yes. More of a discussion piece than an actual surgery that we're doing with much regularity. And, you know, not different from on block surgeries. They're hard surgeries. You have to undermine, you know, find that plane, which is very doable. But you have to extend your plane of dissection all the way back below the matrix. So the matrix is floating freely. And then you really have to correct it and potentially even like over-correct it a little bit because it ends up being a rotation flat. All rotation flats, Lenzugo described the concept of pivotal restraint, you know? So they're going to shrink a little bit. And then they're a sliding flat. They're going to rotate back. So you have to like over-correct a little bit, knowing that there's going to be a natural shift. Just very morbid procedures. And patients are going to, I've had them really try to twist my arm sometimes successfully to do the surgery. And as many successes that I've had have had more not successes in those, those age group. And then that really, you're going into a surgery where you can't predict the surgical outcome as a hard one to a hard pill swallow. And I'll tell them that. And so you're finding the sweet spot of a patient who it's not going to revert to normal, but they don't have a lot of secondary signs yet is. So I'm going to say it's really helpful to hear that level of detail from two experienced surgeons like yourself. Because I see a lot of patients with this condition and I'm explaining the pathophysiology and the malalignment. And it sounds so simple. Well, if it's malaligned, why can't you just go ahead and rotate that for me. And I think this is really helpful for me. And hopefully for others listening to be able to really give a good detailed explanation of that. And why it's probably not the right option for most people. You know, the other thing we talk about is the nuclear option. We mentioned this in the paper too. But some people who have true end stage malalignment, you've exhausted everything else, they can't do conservative measures. There is a place for total chemical ablation of the nail with phenol or another one with this TCA or sodium hydroxide. And then they will have no nail. And we mentioned this and we have a reference to it too. There are medical tattoo artists that can give people remarkably normal appearing from a distance toenails. So that is an option. And that's always my last thing. Because you know, you want patients to have some hope. You don't want to make it a hopeless thing. You know, it's like, okay, if we're really button our head against the wall here, we'll get rid of your nail. And if you're unhappy with the result, then there's an option there too. So I think that's sort of my little, it sounds weird, but ray of sunshine at the end of these encounters. And then I'll pull up on the iPad, the pictures of these toenail tattoos so they can see them. And then we get a kick out of that. Got to find a medical tattoo artist in my area to a lot of people would do the the nipple tattooing after a mastectomies. I talked to them. Same people, same people. Yeah, you know, I'd heard of like the prosthetic resins for nails. I'd never heard of the nail tattooing. So that's a really good pearl for patients who want that. And I think to your point, it really is a lot of shared decision making when it comes to treatment, right? Or these kind of supportive options. So it's like April said, so wonderful to hear how you describe to your patients. And selfishly, as you know, I just had a baby. She's four months old. And I was looking at her toes the other day. I was like, oh my goodness, she has a malaline toenail. These really cute toes. And like you said, she's otherwise developmentally fine. It just it got me thinking like, you know, you know, my pediatrician for my daughter noticed like her ears were coming out. She was like, we can take back her ears. And I was like, it's so interesting that my pediatrician knows about taping ears, but like no one has ever looked at the toes. Like, should we be educating pediatricians about this so that they can educate their patients? Is there anything that's been looked at about like, shoe wear introduction tight socks like in these kiddos or how would you kind of go about if you did see like a four month old them in terms of counseling? That's great. I mean, talk about area of needing a little more attention and explanation. Maybe maybe a quick letter to the piece journal would be good. Yeah, I mean, how we're going to approach it with with those kids, it's all education. Yeah. And you know, the chance there is that now you have the parents attention. So that if this they start developing any signs, that is the kid that you would do surgery on, because you're catching at the right moment. But I think you're exactly right. This is, Lord, I think we're just happy the kids doing well. Otherwise, we'll be a lot of attention to the nails. But, you know, nails are like the red head step child of dermatology and now pediatrics. They just ignore it. So that's a good call. Yeah. I mean, I think reassurance goes a long way. I will often offer to see these patients, because I have had I've seen kids in that zero to six month age range. And the parents are really concerned. And I will offer to see them and follow up even though I know we're not going to change anything, right? But I continue to see them a little bit to reassure. And then right, start counseling as they get towards that footwear stage to just like net set, like really pay attention to the growth of their feet and what kind of shoes they're in and how much they are getting, you know, trying to limit their microtransmitters that you can. I mean, these are anecdotal stories, but they're anecdotes of anchor taping for mallimits. So that would be one thing I would probably discuss with young parents and show them. And that's not invasive. You know, could we anchor tape in a way that would like splint it back to, you know, a more normal alignment. I don't know, you know, but yeah, pulling on the medial nail fold. I would bet, you know, you have the, so it's lateral male line, it would be, yeah, on the, you'd be taping it immediately to pull it in the medial direction exactly. But it would be anchored on the plate. And if you did it enough, a whole lateral side, Eckhart, I don't think he has really nice pictures of this. And you can put like the tape on the digital side sort of stabilize your tape horizontally and then vertical stripes coming down from the plate that then attach to that tape on the side. You can really torque it. That's interesting. Yeah. Yeah. That's interesting. I think it was really important that you distinguish in your paper lateral malignment at the nail unit versus an underlying bony abnormality or versus, you know, associated or not associated with one, right? Because I imagine that also changes the way you think about counseling some of these patients, right? Like if they do have a massive bunion or there is something else going on. And I'm wondering if you could kind of expand on that as well. I think that in those patients, it is helpful for them to understand how the biomechanics of their feet affect the nail because for a lot of them, they're disturbed by the fact that they live for 50 years without these changes in their nails. And then it's only over the last 10 to 15. And this is the time frame that then coincides with the bony changes to the feet. So I think from an acceptance point of view, it can be very helpful for them if you can explain that and show them that not only does your bunion affect your shoe size or whatever else, it does affect the nail unit too. There's collateral damage. And then I think it can also help with, you know, if they are having other significant symptoms, is this someone who gets a referral to podiatry to talk about orthotics, to talk about possible surgery? And potentially could that with correction of the of the bony structure could that lead to some amount of secondary correction to the nail unit? Yeah, I totally agree. I totally agree. That, I mean, going back to the multi-disciplinary management, that would be a good one. And finding a podiatric surgeon that is up to speed on that would be important. And there are many. And I would basically encourage, whoever's listening to this, to look at the nail council website and search for podiatrists who are members, they'll be all up to speed on this. And you know, in the time that I've seen consults, sending to podiatrists, I think there's a very, very high threshold to do these surgeries. And of course, it really depends on expertise and whatnot. But if there's no, like, ambulating pain or there's no, like, symptomatic issue, I find that the bony abnormalities are kind of like, may or may not change the nature of your nail, not, you know, worth doing. So it is such a tricky conversation. I imagine. Yeah. And you know, function and symptoms are bad. That's what we should fall back on. I mean, when we look at people, they're, we look at a lot of people's feet, right? More than most dermatologists because we're looking at everyone's nails. And there are a lot of, you know, funky-looking feet that function just fine, right? That should not be touched, especially in more active people, but they, they work just fine. So yeah, leave those alone. I find too with a lot of the really active types. If you are explaining to them that a lot of these nail changes are collateral for their active lifestyle and things they enjoy doing, a lot of people, that's okay. You know, they get it. And obviously, like Nats said, you would never tell someone to change their lifestyle and they have to improve their nails. And I find there is some comfort in that. They're like, okay, I beat up my nails because I love to run marathon. Yeah. That's what it is. I wonder if the barefoot shoes are better for, do we know this? Are the barefoot shoes better for toenail? Like the beep drone? Yeah. I mean, I think you still could get something. There's probably something about the elevated heel pushing our foot forward, you know? And the running shoe, especially being narrower. I mean, I definitely see a movement now in sort of some, some of the running shoes, some of them are just like cross-training weight lifting shoes, just to have a wider toe box now because they, there's an understanding that your toes are supposed to display when you're standing still. So I do think we're seeing more wide-toed, you know, sports shoes now as a norm. But I wonder right, if you remove the arch support, if that changes this at all. I don't think we have information on that. I would love to see information on that. I'm super interested in the barefoot shoe movement. Let's see your feet, but he got on. Ready? I have great toes feet shoes on. I have socks on, but I'm a big fan of some of these barefoot shoes. The like the three things they talk a lot about in that movement are the wide toe box, which for me is the most important, and then the no drop, and then also having a flexible sole. And I don't know how much those second and third things affect it. So I'm really most interested in the first, but they probably all do play their role. And so I'm trying to get a lot of my patients into some of those wide toe box shoes. The altras are good. The unfortunate thing about those shoes is they tend to be pretty expensive. But there are some on Amazon, Hobie Bear, and you know, different brands that I would love to hear more like feedback on people as they switch to them or see some kind of a paper come out that talks about this. You know, they're not like as common anymore. I had two or three years, so I would wear those insane looking five-toed, you know, shoes. And one of them was all brown, and it was my, they were like my bare feet. It was like furry. I still have patients who ask me about them. And how were they for your nails? Never looked at it. Nails were good, but they, you know, you can't wear socks, or at least I didn't know I could wear socks with them. So it is, and it's kind of smelling over time and it's like that the short-lived pattern. Yeah, no, this is such an amazing conversation. And I think kind of to close out our discussion, maybe we can loop back around to something that you mentioned at the beginning, which was the fact that all these patients think they have nail fungus, right? So how do we have this conversation with patients? And how do you or when do you feel like it's helpful to test and nail clipping for these patients? Yeah, this is a central part of the visit is addressing the nail fungus concerns. I find I have a low threshold to clip these patients for two reasons, two main reasons. The first being either patient who has been told that they've had fungus their whole life, they've been through multiple courses of turbidity, and they tried every topical there is, and they're very frustrated. They have a hard time when you say, after they've seen, you know, 15 other people, when you say, "No, no, it's not fungus," right? They just, how can they believe that? Everybody else said it was. The internet says that. Exactly right. In these patients, I, you know, go through the whole conversation about malwindment, and then I will oftentimes clip them more to prove to them that they don't have fungus, right? So they can put that part to bed and then work on the modifying factors and the acceptance, because a lot of this disease or this disorder, if you will, is acceptance. So those patients, I'm fairly quick, and not now we're speaking about this earlier. You just have to be really careful that you're not over calling these results, right? You're going to see yeast forms. You might see yeast in sacrifice there. You don't want to read into that too much, and then treat these patients, giving them another sort of false hope situation. If patients have asymmetric symptoms, they're malign nails, so both nails are malign, but one of them just looks much different than the other. Oftentimes, I will clip that asymmetric nail to make sure they don't have a concurrent fungal infection. And in both of these cases, you will sometimes get a positive PCR or PAS, of a dematified, a true dematified infection. And so these patients, I will treat that dematified infection, but managing their expectations as to what the nail is going to look like after treatment is really, really important, right? We can treat the fungus. It might improve the appearance marginally of your nails, but it's not going to correct the underlying malignment. And so they shouldn't expect a phenotypically normal appearing nail after that treatment. Yeah, yeah, just temper their expectations. And then treatment is always, almost always optional with anachromicosis, but in particular, this case, okay? You still have malignment clinical, clinically, it may be that I don't think you're getting it, but if they've all that end-stage signs of what we call end-stage malignment with all the signs, getting rid of the fungus is not going to change that. But if they have moderate disease, hypercarotosis, can we get them better? It's a case-by-case basis. But definitely not over-calling. I think you're totally right, because you have a warm wet space underneath this nail. There's definitely going to be a mycotic element presence. I think the presence of molds are fairly common, as colonizers there. Can I ask, would you get an x-ray in a situation like that to an asymmetric changes to rule out like exhaustoses or anything else, or do you find that that's high yield for malignment at all? You know, getting an x-ray for one nail that's different than the others is, it's a thick shear top. This is always a good idea for the occasional case where they're actually bone pathology. So if you can think of something that would cause the disorder, probably worth doing it, because it's low risk, low cost, potentially high reward. And so the indications for your x-ray, as you mentioned, are multiple, right? So yeah, if you think there's some bone abnormality, definitely get an x-ray. Good point. Thank you so much. This was incredibly helpful. I feel like they're taking away so many pearls and they're looking to these barefoot shoe movement. Thank you for teaching me about that. I'll send you guys a picture of my brown shoes later. I would love to see it. You know, thanks so much for having us. This was, this was like really, we've been talking about writing this paper for years. And you know, tip of the cap to Hannah Porter, who really helped us bring this across the finish line, because we were just sort of struggling with it 90% done. For years. Yeah, and years and adding to it, and we went back and forth with Bertron multiple times. And so yeah, I'm glad that I'm glad to have that have it out. Yeah, Major Kudos to Hannah. Yeah, honestly, yeah, it's really a gift to us and dermatologists and anyone who takes care of people who have nails, because it's great education to have out there. So I'll say, Nat Julia and Jasmine, thank you so much for joining us on this episode of Clippings. I want to thank our listeners for their attention. Let us know how we're doing and which articles you'd like us to review on the show by contacting Jerry, g-e-r-i dot [email protected], or you can find us on Instagram at nail disorders. The goal of the Clippings podcast is educational and informational and intent and is not a substitute or resource for formal medical advice. Listeners should not delay formal medical care for any condition or medical question they have and the views are solely those of the discussants and use of any content is at the user's own risk. [Music]