Manicures

Enthusiasm for manicures is at a high amongst young populations and has led to a growth in nail cosmetology in the last decade. The global nail market was projected to reach $15.55 billion in 2024 as the number of nail salons has increased abundantly. Gel and acrylic manicures have gained popularity for their sleeker look, longer-lasting effects, and less aftercare. However, the longer-lasting effects are due to a more extensive manicure technique using ultraviolet (UV) light to cure the polish.

As a result of the increased enthusiasm for manicures and more abrasive techniques for longevity, it is important to look at adverse outcomes associated with different manicure types to improve counseling and management.

Nail manicures offer a wide range of application methods, costs, and styles, with over 10 distinct forms available in the cosmetic industry. Acrylic nails are a type of artificial nail enhancement created from a mixture of both ethyl methacrylate (EMA) liquid and powder acrylates that harden with air exposure and do not require UV photocuring. Acrylics are also referred to as “sculpted” or “porcelain” nails, typically sculpted and shaped over bare nails with artificial tips. Gel polish is an acrylic-based nail product composed of polymerization photo-initiators and (meth)acrylate monomers—such as 2-hydroxyethyl methacrylate (HEMA), methacrylates, and acrylates—which belong to the (meth)acrylate family of esters. Three layers (base, color, and top coat) are cured under UV/LED light, causing a free-radical reaction that hardens the polish.

Acrylic and gel manicures are reported to be the most common kinds of manicures and were also linked to the highest incidence of adverse outcomes.

The most common adverse outcome associated with gel manicures was allergic contact dermatitis (ACD). ACD involving nails typically presents with redness around the nail, swelling, onycholysis (separation of nail from the nail bed), and nail plate degeneration, often accompanied by pruritus (itching) or tenderness. Nearly half of all articles discussing gel manicures reported ACD as an adverse outcome. Similarly, 60% of articles discussing acrylic nails reported ACD as an adverse outcome. Interestingly, the conglomerate of studies suggests that the presence of acrylates may be the primary risk factor for adverse outcomes, especially ACD, for both acrylic and gel manicures. In a review of ingredients in 394 nail products, 2-hydroxyethylmethacrylate (HEMA), a type of acrylate, was listed in approximately 60% of products.

Of note, ACD due to acrylates tends to occur at the site of application and less commonly occurs in distant areas such as the face and eyelids. Moreira et al. found that distant ACD can be explained by hand transportation or airborne dissemination of the allergen, a finding corroborated by Kieć et al. Ocular symptoms reported by participants in Kieć et al.'s study included itching, redness, and tearing. These findings in conjunction suggest that exposure to nail cosmetics should be considered when evaluating eyelid dermatitis.

Another common clinical pattern observed is pseudo-psoriatic nails (Google it!), particularly in individuals wearing acrylic products. The presenting symptoms are similar to those seen in psoriatic nails, such as onycholysis and significant subungual hyperkeratosis. Pseudo-psoriatic nails are believed to be caused by the traumatic removal of firmly attached acrylic nails, though they have been seen prior to such removal processes.

Although there are similarities between the adverse outcomes of gel and acrylic manicures, some outcomes are more so associated with one type over the other. Worn down nail syndrome (WDNS) is described as a triangular area of nail thinning with pinpoint hemorrhages and dilated capillaries. Acrylic nails often require abrasive mechanical techniques to remove, which can lead to WDNS. Dickison and Smith were the first to identify chronic urticaria due to gel nails. All 17 subjects developed pterygium inversum unguis (PIU) (a nail disorder where the skin under the nail (hyponychium) adheres abnormally to the underside of the nail plate) presenting as adhesion of the nail bed and hyponychium to the ventral nail plate, after 2–5 years of gel polish application. They also suggest that PIU secondary to gel manicure is frequently overlooked but not uncommon.

Allergic contact dermatitis mimicking angioedema was also identified as a potential outcome. In one case of recurrent nonpruritic chelitis and angioedema, patch testing with the European baseline series reported reactions to many acrylates and methacrylates. Cessation of regular manicures resulted in rapid resolution. In another reported case, inspection of gel nail products revealed fragrances, (meth)acrylates, and polyurethane (isocyanates). These cases highlight important considerations of the non-occupational and cosmetic causes of angioedema.

At-home manicures are associated with a variety of adverse effects, but most prominently ACD and burns, especially in the absence of an expert beautician. A cross-sectional survey of 199 individuals found that home-acrylic-nail-kit use was associated with earlier development of skin reactions and more frequent nail damage than professional acrylic manicures. They also learned that 68% of participants learned about at-home nail kits through social media, and 74% received training through online tutorials. 83% of home nail kit users experienced skin reactions for the first time after their first time using home kits.

Home products also allow children and adolescents easy accessibility to chemicals and allergens in nail products. Kelemen et al. highlight several cases of adolescents experimenting with beauty products and using cyanoacrylates commonly used in nail glues. However, ill knowledge of the dangerous exothermic reaction between cotton fibers and nail glue led to several cases of full-thickness thermal burns while applying artificial nails.

Other popular, but harmful, manicure types include Russian manicures, dip manicures, shellac manicures, press-on nails, etc. (Table 5). Russian manicures file and remove the cuticle, an important part of the nail unit, and serve as a barrier to prevent infection and paronychia.

Another popular type is a hybrid manicure, which involves chemical exposure, UV radiation, and mechanical abrasion. This decreases nail strength by compromising the integrity of keratin. Hybrid manicures that use daylight instead of UV or LED to cure gel manicures also lead to hand dermatitis and ACD. (Meth)acrylate monomers are present in hybrid nail lacquers, and this manicure type harbors the same risks as UV and LED-cured manicures.

Classic manicures that do not use curing techniques historically contain allergens such as toluene, formaldehyde, and dibutyl phthalate (DBP). A recent study shows that these allergens are falsely reported to be eliminated from nail polish products, known as “3-free” products, and that chemical exposures to formaldehyde and toluene are still apparent in classic nail lacquers. It is unclear why these products are falsely reported as “3-free,” but consideration of these allergenic irritants should be given to patients with nail ACD who get classic manicures.

With the increased popularity of manicures, awareness of possible complications of different types of manicures prompts appropriate education. Recent recommendations include restriction of the application of long-lasting nail polishes to professionals and advising against home usage. Avoidance of contact with acrylate-containing products resulted in completely clearing dermatitis in 80% of patients, supporting the inclusion of HEMA allergen in baseline allergy testing. This could prove beneficial in cases of unclear cheilitis and angioedema as well

Various steps were identified as harmful throughout the process of getting a manicure, such as improper sanitization between clients. Even with the knowledge that sharing equipment could lead to viral infections, individuals continued to share equipment.

The above is not say do not get a manicure just that you should be aware of the issues and risks and always make sure that you are seeing a properly qualified nail technician or professional.

NOT MY OWN WORK! The above is taken from: (Italics are mine and I have changed some of the medical terms into simpler to understand language)

K. Javaid, S. Mistry, M. Tchack, N. Musolff, B. Rafiq, and B. Rao, “ Dermatologic Conditions Associated With Various Types of Popular Nail Cosmetics: A Systematic Review of Existing Literature and Future Recommendations,” Journal of Cosmetic Dermatology 24, no. 10 (2025): e70519, https://doi.org/10.1111/jocd.70519. Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, USA et alia.