Treating hay fever.

The ideal setting for this approach is a special unit in which appropriate skills can be practised and taught. Some large hospital centres have established toenail clinics calling on the interrelated specialties and catering for many patients. Yet a group practice may be the best place to site a toenail clinic: costs are generally lower, and many surgeries and health centres provide a setting for close liaison with other disciplines such as district nurses and chiropody services. The patient receives his treatment sooner from the general practitioner at the time of first presentation with a shorter waiting time. Referral to hospital invariably causes delay, and the hospital visit can be a forbidding experience. Well tested techniques can be learnt and applied by the general practitioner. Treatment has to be tailored to two main groups of patients. When the patient presents with an acutely infected ingrowing toenail simple conservative measures are very unlikely to produce a prompt response and control of infection. Avulsion of the nail is more likely to achieve this, but removal of the whole nail is not necessary; a sliver of the nail edge may be taken off, as suggested by Fowler,' and this can be done without local anaesthetic with minimal discomfort to the patient.2 Another approach with equally reliable results is the gutter technique, carefully assessed and described by Wallace et al.3 In the case of the recurrent or chronic ingrowing toenail some form of ablation of the germinal matrix is needed, and there seems very little to choose between segmental excision4 and phenol ablation' in terms of results. The choice of technique should be left to individual preference. Neither is "easier" and both require close attention to detail, not only of operative techniques but also of postoperative dressings and careful follow up in the short and long term. Total nail bed ablation should be reserved for the uncommon case where the whole nail is embedded and in onychogryphosis. An increased understanding of the pathophysiology of pollenosis (see leading article last week, p 1) enables treatment to be based on rational grounds. H, antihista-mines have long been known to be an effective treatment of hay fever. Two new antihistamines, terfenadine and astemizole, have recently become available which are free of the sedative and anticholinergic side effects associated with the older preparations.'2 Though both of these drugs are potent H, receptor antagonists, they differ in their pharmaco-kinetics. …