Infection Control Right at Your Fingertips

Sept. 1, 2007
Nail care is vital in the prevention and spread of disease. Health-care professionals must be willing to make changes in their habits to meet the demands of infection control.
Click here to enlarge image

Nail care is vital in the prevention and spread of disease. Health-care professionals must be willing to make changes in their habits to meet the demands of infection control. They must be willing to sacrifice style for the health of their patients.

by Noel Kelsch, RDH

No single question in my infection-control continuing-education courses causes more controversy than this: “Can I have artificial fingernails in dentistry?” Acrylic, sculptured, photo-bonded, Teflon, press-on ... these nail-enhancing products termed nail prostheses by dermatologists can be a hazard to your health and the health of your patients. Recent studies demonstrate that health-care workers with artificial fingernails are more likely to harbor pathogens than those with natural nails.1,2,3 Wearing artificial fingernails has been linked to cross contamination in the health-care industry.4

One of the most important functions of any health-care professional is infection control. The key to infection control for both patients and clinicians is right at our fingertips. When I lecture on infection control, this part of the anatomy presents the biggest controversy. You might think that I am asking my audience to do something drastic like shave their heads (which might not be a bad idea with all those aerosols floating around). In reality, I am simply asking them to take a look at the facts regarding the keratinized portion of their hands, to think about those nails at the end of their fingers. When clinicians understand the function, risks, and importance of nails, I am sure they will change their nail care and cosmetic habits.

What Do Nails Do?

Nails serve many important functions. They help us pick up and manipulate everything from instruments on our tray to pennies on the floor. They protect the tips of our fingers and the nerves surrounding the area. Nails reflect both our general health and the effort we put into personal care. For many, they make a personal, artistic statement of who they are, sporting pumpkins at Halloween, hearts for their true love, and daisies in springtime.

Nail Anatomy

Nails are produced by living skin cells in the finger. They are composed primarily of keratin, a hardened protein also found in the skin and hair. Nails grow from the matrix. As older cells grow out and are replaced by newer ones, the newer ones are compacted and take on a hardened form. Nails grow an average of 0.1 mm each day. This varies depending on age, time of year, activity level, and heredity. Nails grow faster in the summer, and their growth is affected by disease, hormone imbalance, and the aging process.5

Nails are a great clue to general health. They can be a clue to internal conditions,6,7 and play an important part in regular physical exams. See Table 1 for examples.

Nails and Disease

The nail and surrounding skin function as an important barrier to infection. Compromising those areas with nicks, cuts, and abrasion leaves the area open to infection. Unclean nails provide a warm, moist, nutrient-filled environment perfect for bacteria and fungus to grow and thrive. Disorders of the nail can spread infection to both the clinician and the patient. Nail infections affect our senses of touch, as well as our ability to manipulate objects and even perform our jobs.

Click here to enlarge image

The nail bed can harbor bacteria and fungus that can spread from person to person. The most common infection of nails is fungal (onychomycosis). It affects about 12 percent of all Americans.6 Nail fungus tends to run in families because of an inherited tendency, but not everyone is susceptible. It is rare in children unless one or both parents are infected. Fungal infections of the nail are very important to people who have other diseases such as diabetes and those with suppressed immune systems. Patients who are HIV positive, cancer patients, and transplant patients need to be especially careful to avoid contracting these diseases. The two most common are dermatophytes and candida (yeast) in the fingernails. Diagnosis includes a laboratory test to identify the type of infection since treatment is based on the specific agent present. Treatment includes antifungal creams, lotions, gels, as well as lacquers.

Click here to enlarge image

The nail is a very difficult area to penetrate when treating fungal infections. Often, an oral medication such as itraconazole or fluconazole must be used and may require monitoring of liver function. Debridement, or removing the infected part of the nail, may enhance the effectiveness of treatment. In some situations, dissolving or surgically removing the nail may be helpful.

To prevent fungal infections from occurring, the American Dermatological Society6 recommends specific strategies for nail care. See Table 2.

What About My Nail Salon?

Nail salons are popping up on every corner. Nail cosmetics is a booming business! My daughter asked me to find her cell phone after she had left it at a nail salon in town. She couldn’t remember the name of the place and told me it would be simple to just look up the salon on the Internet. I mean, how many could there be? I searched for nail salons in my small town and was taken aback when 32 listings appeared.

Infection control in a nail salon is only as good as the staff members’ understanding of the subject. Contracting an infection is the most serious health risk related to nail cosmetics, particularly from manicure and pedicure tools and other implements that have not been properly sterilized. Improperly sterilized implements can transmit viral infections such as HIV, hepatitis B and C, and warts to unsuspecting consumers. Most nail salons take sanitation very seriously and follow strict disinfection guidelines, but consumers should not shrink from about asking how their implements are cleaned. Consider a salon with cleanliness in mind and ask yourself these questions:

  • Are the stations clean?
  • Does the nail technician wash her hands between clients? Are there dirty implements lying around?
  • Does the salon appear clean? If the salon does not appear clean, move on.
  • How does the salon cleaning its tools and test the process? To protect against infection, consumers can bring their own tools to be used at the salon. In one salon I visited, all of the instruments are autoclaved. I asked the cosmetologist how often the autoclave is tested, but no one in the salon knew what I was talking about.

Artificial Nails

Now that you know how to care for your natural nails, here comes the part of my lecture that causes hands to raise - artificial nails. I ask health-care professionals a very simple question: With patient safety in your hands, what are you willing to sacrifice? It is right at your fingertips. A real threat to patients lurks at the very tips of health-care workers’ fingers. Even when properly washed and gloved, the risk of infection is still there. The threat is pathogens harbored beneath artificial fingernails. If clinicians forgo artificial fingernails, it could make a significant difference in infection control. Studies have shown that artificial nails, as well as chipped nail polish, possess a greater amount of gram negative bacteria and pathogens than natural nails. The grooves and rough areas create a prefect space for bacteria to reside.5

Artificial fingernails have been linked to outbreaks of postoperative infection caused by Serratia marcescens and Candida Ostemyelitis and diskitis following spinal surgery. The event that really brought this issue home was the neonatal intensive care unit outbreak of Pseudomonas aeruginosa that was attributed to a nurse’s artificial fingernails. Chipped nail polish is another area of concern for harboring pathogens. As early as 2002, The Centers for Disease Control recommended that health-care workers not wear artificial nails or extenders. Even the Board of Cosmetology reported that fungal growth occurs more under artificial nails.8

Nail care is vital in the prevention and spread of disease. Health-care professionals must be willing to make changes in their habits to meet the demands of infection control. They must be willing to sacrifice style for the health of their patients.

The Bottom Line

The World Health Organization guidelines on hand hygiene state: The wearing of artificial nails can contribute to hands remaining contaminated after washing or using hand gels. Let your conscience be your guide.

About the Author

Noel Brandon Kelsch, RDH, is a freelance cartoonist, writer, and speaker. Noel’s cartoons can be seen in RDH magazine and her articles have been published in both dental and nursing trade magazines, as well as books. She has received many national awards including Colgate Bright Smiles Bright Futures, RDH/Sunstar Butler Award of Distinction, USA magazine Make a Difference Day award, President’s Service award, Foster Parent of the Year, and is a five-time winner of the Castroville (Calif.) Artichoke cook-off! Her family lives in Moorpark, Calif. She can be contacted at [email protected].


1. Bergfeld WF. 2001.

2. Centers for Disease Control and Prevention. Fact Sheet: 12 Steps to Preventing Antimicrobial Resistance Among Surgical Patients.

3. Association of Perioperative Nurses, Stands, Recommended practices and Guilelines, 2007.

4. What lies beneath your artificial nails? Dermatology Insights Fall 2001; 26.

5. Johnson J. 2006.

6. Accessed 12/12/06.

7. Dermatology Insights 3(1):28.



Nail Care

  • Keep nails short to minimize trauma, injury, and limit space to harbor bacteria.
  • Wash and dry hands and nails properly to prevent infection.
  • Don’t bite your nails; they are a source of bacteria and infection.
  • Cut nails straight across and round them just a little at the tip. This will make nails stronger. Use sharp nail scissors or clippers to do the job.
  • Do not file nails to a point; that will make them weaker. If nails need to be filed, use a fine-grade, clean file and change or disinfect file frequently. Do not share nail files.
  • If nails have any problems or become infected, get a proper diagnosis from a dermatologist.
  • Try not to use nail polish remover more than once a week, because it causes the nail to dry out. Dry nails crack and split more easily.
  • A vitamin called biotin has been shown to make nails stronger. It is available at health food stores.
  • Remove nail polish at the first sign of chipping.
  • Artificial nails should not be worn by health-care professionals, because they harbor pathogens. Health-care professionals should have short, clean, well-kept fingernails.