Nail Polish Does Not Significantly AffectPulse Oximetry Measurements in Mildly Hypoxic Subjects
Loren G Yamamoto MD MPH MBA, Julienne A Yamamoto, Joelle B Yamamoto,Brennan E Yamamoto, and Patricia P Yamamoto RNC
BACKGROUND: The effect of nail polish on pulse oximetry measurements in non-hypoxic subjectshas been studied extensively. Some studies found that nail polish decreased pulse-oximetry (SpO2)values, whereas others found no effects from nail polish. OBJECTIVE: To determine if nail polishaffects SpO2 measurements in mildly hypoxic subjects. METHODS: At high altitude, 5 investigators,whose mean oxygen saturation was 91.3% (mild hypoxia), and with 2 brands of pulse oximeter andoximetry probe, obtained SpO2 measurements from a finger with nail polish and from the matchingfinger on the opposite hand without nail polish. We tested 9 different nail-polish colors and made210 pairs of SpO2 measurements. RESULTS: The mean SD SpO2 values from the fingers with andwithout nail polish, respectively, were 91.4 4.1% and 91.2 3.5% (difference 0.2 3.2%, 95%confidence interval 0.2% to 0.4%). CONCLUSIONS: With the pulse oximeters and oximetryprobes we tested, nail-polish had no significant effect on SpO2 in mildly hypoxic healthy subjects. Keywords: pulse oximetry, SpO2, nail polish, hypoxia, high altitude. [Respir Care 2008;53(11):14701474. 2008 Daedalus Enterprises]
Pulse oximetry is an essential monitoring technology.Clinical decisions are often made based on pulse oximetryoxygen saturation (SpO2) measurements. Pulse oximetryworks by transmitting light onto one side of a digit (orother tissue appendage) and sensing the light transmissionon the opposite side of the digit. Standard pulse oximetryuses 2 light sources and 2 sensors. The red light source isvisible. The infrared light source is invisible. Changes inlight transmission through the digit permit the pulse oxime-ter to calculate oxygenation, based on the assumption thathemoglobin A is pulsing through the capillaries. The tech-nical aspects of pulse oximetry have been summarized by
others.1,2 New developments in pulse oximetry are im-proving its capabilities.
Since pulse oximetry probes are most commonly ap-plied over the fingernails, it has been a concern that nailpolish impedes light transmission. Previous studies havereported conflicting results (Table 1). Earlier studies foundthat some nail-polish colors reduced SpO2 by clinicallyimportant percentages,4-6 but more recent studies foundSpO2 measurements accurate even with opaque nail-polishcolors, including black, blue, and purple.8-11 Controversyremains, because the earlier studies found SpO2 decreasesof 510%, whereas in the more recent studies the SpO2decrease was 2%. All those studies used only non-hypoxic subjects.
We studied the accuracy of SpO2 measurements throughnail polish in mildly hypoxic subjects. SpO2 measurementsuse the color of the blood to measure oxygenation, so ahypoxic subject could have different light-absorption char-acteristics that might interact differently with certain nail-polish colors. For example, red nail polish could falselyincrease SpO2 readings, and blue and purple nail polishcould have the opposite effect. The effect of nail polish onSpO2 in non-hypoxic patients cannot necessarily be extrap-olated to hypoxic patients.
Loren G Yamamoto MD MPH MBA is affiliated with the Emergency De-partment, Kapiolani Medical Center For Women And Children, and with theDepartment of Pediatrics, John A Burns School of Medicine, University ofHawaii at Manoa, Honolulu, Hawaii.
The authors report no conflicts of interest related to the content of this paper.
Correspondence: Loren G Yamamoto MD MPH MBA, Department ofPediatrics, John A Burns School of Medicine, University of Hawaii atManoa, 1319 Punahou Street, #733, Honolulu HI 96826. E-mail:firstname.lastname@example.org.
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Hypoxia was most conveniently induced by conductingthe study at high altitude. The summit of Haleakala Na-tional Park, Maui, Hawaii, at 3,048 m, is easily accessibleby car. The calculated air pressure is 523 mm Hg (com-pared to 760 mm Hg at sea level). At 523 mm Hg, a 0.21fraction of inspired oxygen yields an ambient PO2 of110 mm Hg (compared to 160 mm Hg at sea level). Thearterial PO2 at 3,048 m is approximately 5570 mm Hg.
The 5 study subjects (ages 50, 49, 20, 17, and 15) eachapplied nail polish (Table 2) to the digits of one hand. Thecorresponding digits on the other (control) hand had nonail polish. Two coats of nail polish were applied, andeach coat was allowed to dry before applying the next coator the pulse oximeter probe. SpO2 measurements were madeserially on the nail-polished digits and the non-nail-pol-ished (control) digits (same digit on the opposite hand, notnecessarily in that order). The measurements were con-ducted in a sheltered environment (an observation enclo-sure or a vehicle), because at the summit of Haleakala theoutdoor temperature is cold, which affects perfusion. Mostof the measurements were made with the subjects at rest,after achieving an oxygenation steady state. We also madesome measurements following a brief jog or brisk walk.
We used 2 pulse oximeter models: RDS1, Masimo, Irvine,California, and N20, Nellcor, Pleasanton, California. A dis-posable neonatal digit probe and a reusable adult clip digitprobe were used with the Masimo RDS1. With each RDS1measurement we also recorded the perfusion index, which isthe percentage of pulsatile signal to non-pulsatile signal. Witheach Nellcor N20 measurement we recorded the number ofperfusion bars; in Nellcors perfusion-measurement sys-tem, the maximum number of bars is 14. The purpose ofusing 2 different pulse oximeter models and different probeswas to study whether observed differences were consistentbetween the different pulse oximeters and probe types.
The pulse oximetry probes were applied in an anterior-posterior direction only (no oblique or lateral orientationmeasurements). The anterior-posterior alignment maxi-mizes the effect of the nail polish. Each digit was mea-sured with the probes light on the nail side of the digit,then the measurement was repeated with the light on thepad (palm) side of the digit. This was done to confirm thatthe nail polish versus control comparisons were consistentbetween the different methods of applying the probe.
Pulse oximetry measurements are continuous and notalways in a perfectly steady state. We observed the nu-meric values and the pulsation/perfusion data and recorded
Table 1. Studies of the Effect of Nail Polish on Pulse Oximetry Measurements
First Author Year Pulse Oximeter Summary
Kataria3 1986 Nellcor, model not specified Nail polish (color not specified) had no effect on SpO2.Rubin4 1988 Ohmeda Biox 3700 31 nail-polish colors were tested on one subject. Only the
Blue Flame color decreased SpO2, from 97% to 87%.Two other blue colors and the other 28 colors tested didnot decrease SpO2.
Cot5 1988 Nellcor N-100 Red nail polish had no significant effect on SpO2, but purple,black, green, and blue decreased SpO2 by 1.7, 3.1, 5.2, and5.9%, respectively, compared to controls.
White6 1989 Ohmeda Biox 3740 and Nellcor 200 With the probe in the anteroposterior orientation there wereSpO2 decreases, as described by Cot,
5 but with the probepositioned sideways on the finger, the nail polish caused noSpO2 differences.
Battito7 1989 Not specified Fingerprinting ink resulted in falsely low SpO2 values.Brand8 2002 Nellcor N-209A Ten nail-polish colors tested. None of the colors affected
SpO2, compared to the controls.Chan9 2003 Ohmeda Biox 3740 Small SpO2 decreases with all 10 colors tested. Only black and
brown decreased SpO2 by 2%. There were no differenceswhen the probe was placed in the lateral (side to side)orientation.
Hinkelbein10 2007 Siemens SC1281, and Nellcor DS-100A probe All 9 nail-polish colors tested caused small SpO2 decreases( 2% with most colors), compared to arterial blood gasvalues. Black, purple, and dark blue had larger effects thanthe other colors.
Rodden11 2007 Nellcor N20 and N595 Ten nail polish colors tested. Only red, blue, and brownsignificantly decreased SpO2, but the decrease was 1%.
SpO2 oxygen saturation measured via pulse oximetry
EFFECT OF NAIL POLISH ON PULSE OXIMETRY IN MILDLY HYPOXIC SUBJECTS
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the most dominant value (the most apparently correctvalue), as we do when reading SpO2 values in the clinic.
Our measurement sampling was optimized to comparethe nail-polished and non-nail-polished digits by alwayspairing a nail-polish measurement with a non-nail-polishmeasurement, with the same pulse oximeter and probetype for each pair of measurements. We did not performsimilar pairing with pulse oximeter types, pulse oximeterprobe types, or nail-polish colors, which made the compari-sons between oximeter types, probe types, and nail-polishcolors potentially subject to unintentional sampling bias.
Data were entered into a spreadsheet (Excel, Microsoft,Redmond, Washington) and analyzed with statistics soft-ware (SPSS, SPSS, Chicago, Illinois). Paired results wereanalyzed with a paired t test. Unpaired independent sam-ples were analyzed with analysis of variance.
This study was approved by the institutional reviewboard of Hawaii Pacific Health.
We took 210 paired SpO2 measurements with 5 investi-gators. The mean nail-polish and non-nail-polish SpO2 val-ues, respectively, were 91.4 4.1% and 91.2 3.5%(mean difference 0.2 3.2%, 95% confidence interval0.2% to 0.4%). One hundred forty-four measurementswere made at rest, and 66 were made following a brief jogor a brisk walk (Tables 3 and 4). Although the differentnail-polish colors had different mean SpO2 values, the non-nail-polish values were obtained contemporaneously on amatching digit on the opposite hand. None of the nailpolishes significantly affected SpO2 or the Masimo perfu-sion index or Nellcor perfusion bars.
SpO2 did not significantly differ between the nail-pol-ished digits and the matched non-nail-polished control dig-
Table 3. SpO2 With and Without Nail Polish
SpO2 (mean SD)
All measurements 210 91.4 4.1 91.2 3.5 .35At rest 144 92.7 2.4 92.4 2.0 .27After exertion 66 88.8 5.6 88.6 4.5 .75
BrandMasimo 114 91.1 4.6 90.7 4.1 .24Nellcor 96 91.8 3.4 91.9 2.6 .90
Probe typeNeonatal 124 92.0 3.3 92.1 2.6 .63Adult 86 90.7 5.0 90.1 4.2 .12
Light applied toNail 105 91.0 4.9 90.8 4.1 .45Pad 105 91.8 3.1 91.7 2.8 .59
Nail polish colorBlack 18 93.6 1.6 93.0 2.1 .24Brown/maroon 20 92.2 1.9 91.5 2.4 .24Blue 26 90.7 6.7 90.8 3.6 .83Purple 22 91.2 4.6 91.2 5.2 .99Green 26 89.5 4.8 90.0 4.0 .59Clear/glitter 28 91.5 2.9 91.4 3.0 .79Pink 10 90.9 3.6 90.7 2.7 .78Red 34 91.7 3.5 91.2 4.0 .44Orange 26 92.2 3.5 91.6 2.6 .34
SpO2 oxygen saturation measured via pulse oximetry
Table 2. Nail Polish Brands and Colors Tested
Company Nail Polish Trade Name ColorCompany Product
Del LaboratoriesUniondale, New York
NYC New York Color Long-WearingNail Enamel
Black Lace Creme (black) 119ASkin Tight Denim Creme (blue) 115APurple Pizzazz Frost (purple) 133ABig Money Frost (green) 118AWing It Wine Creme (brown/
White Lights Glitter (whiteglitter)
Big Apple Red Creme (red) 131ATimes Square Tangerine Creme
California ColorsPacoima, California
California Colors Nail Enamel Pink 33
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its on the opposite hand, regardless of nail-polish color,pulse oximeter model, or probe type.
Pulse oximetry measurements are less accurate whenthe patient is very hypoxic, but nearly all of our measure-ments were conducted with modest hypoxia, within therange of demonstrated accuracy.1
Our sampling method was not optimized to comparecolors, pulse oximeters, probes, or measurements made atrest versus after exercise, so differences between thosegroups could be due to sampling bias. However, none ofthe nail-polish colors significantly affected SpO2.
We did not measure oxygen saturation by other methodssuch as arterial blood gas analysis or CO-oximetry, so theSpO2 values were not confirmed by a standard.
The mean SpO2 value indicated mild hypoxia, consistentwith the high altitude. Our results are consistent with stud-ies with non-hypoxic subjects that found no effect fromnail polish on SpO2, which confirms that finding in mildlyhypoxic healthy subjects.
The divergent results of previous studies might be ex-plained by differences in light-transmission between thinand thick coats of nail polish and/or to different nail-polishcolors.
Cote et al described different spectrophotometric ab-sorption at the 660 nm and 940 nm wavelengths used byconventional pulse oximeters as a possible reason that pur-ple, black, green, and blue nail polish decreased SpO2 val-ues by 1.7%, 3.1%, 5.2%, and 5.9%, respectively, whereasred nail polish did not affect SpO2.
Rubin described similar spectrophotometric data for oneblue nail polish that decreased SpO2 10%, but the other 30colors (including 2 other blue colors) did not decreaseSpO2, and the spectrophotometric data were not presentedfor those 30 colors.4
Brand et al found that 3 of the colors they studied (blue,green, and lime) had significant differences in spectropho-tometric absorption at 660 nm and 940 nm, but none of the10 colors they tested significantly affected SpO2.
Hinkelbein et al published spectrophotometric curvesfor 9 nail-polish colors, but only the dark green color hada significant absorption difference between 660 nm and920940 nm, and all the nail polishes they tested caused a 2% SpO2 decrease.
Rodden et al studied spectrophotometric absorption at660 nm and 940 nm, and found the greatest absorptiondifferences in the blue, pink, and white nail polish theystudied; intermediate absorption differences in the orange,yellow, purple, black, and brown nail polish; and smallabsorption differences in the red and green nail polish.Significant differences were found with the red, blue, andbrown nail polishes, but the SpO2 decrease was 1% andthus not clinically important.11
There is some consistency in the spectrophotometricdata in those studies, but there are also important discrep-ancies, which could be attributed to the transparency (dif-ferent light-transmission through a thin vs thick layer ofnail polish) and the specific light-absorption characteris-tics of the various nail polish preparations and colors.Although the human eye perceives a particular color to be,for instance, blue, this is due to a summation of the variousabsorption values within the visible range of light. Colorperception does not necessarily correlate with light ab-sorption at 660 nm (the visible red light). The 940-nminfrared light is invisible, and blue nail polish would notnecessarily have the same light-absorption differen...