Lianne Beck, MDAssistant ProfessorEmory Family Medicine

Fingernails grow 2 -3 mm a month or 0.1 – 0.15 mm a day

Toenails grow 1 mm a month

Beau's lines Transverse depression across the nail plate Occurs when growth at the nail root (matrix) is

interrupted by trauma OR any severe acute illness e.g. heart attack, measles, pneumonia, or fever.

These lines emerge from under the nail folds weeks later, and allow us to estimate when the patient was sick.

Repetitive trauma particularly with long nails, repetitive wetting and drying, detergents, harsh solvent

Metabolic bone disease (nail thinness is correlated with osteopenia)

Thyroid disorder, anemia Systemic amyloidosis (indicated by yellow waxy

flaking) Severe malnutrition More common in women

Onychorrhexis

Presence of longitudinal striations or ridges A sign of advanced age but it can also occur

with the following: Rheumatoid arthritis Peripheral vascular disease Lichen planus Darier's disease (striations are red/white).

Central ridges can be caused by iron , folic acid or protein deficiency.

Associated with severe arterial disease ("Heller's fir tree deformity" -- a central canal with a fir tree appearance -- may occur with peripheral artery disease

Severe malnutritionRepetitive trauma

The beads seem to drip down the nail like wax.

Associated with endocrine conditions, including the following: Diabetes mellitus Thyroid disorders Addison's disease Vitamin B deficiency

Clubbing

Thickening of the soft tissue beneath the proximal nail plate resulting in sponginess of the proximal plate and thickening in that area of the digit.

Occurs in patients with neoplastic diseases, particularly those

of the lung and pleura.

Associated with other pulmonary diseases, including bronchiectasis, lung abscess, empyema, pulmonary fibrosis, and cystic fibrosis.

Others: AVM or fistulas, celiac disease, cirrhosis, and inflammatory bowel disease, congenital heart disease and endocarditis

Pitting

Punctate depressions in the nail plate caused by defective layering of the superficial nail plate by the proximal nail matrix.

Usually associated with psoriasis, affecting 10 to 50 % of patients

Also caused by systemic diseases, including Reiter’s syndrome and other connective tissue disorders, sarcoidosis, pemphigus, alopecia areata, and incontinentia pigmenti.

Any localized dermatitis (atopic or chemical dermatitis) that disrupts orderly growth in proximal nail fold also can cause pitting.

Oil Spot Sign or Salmon Patch

Koilonychia

Transverse and longitudinal concavity of the nail, resulting in a “spoon-shaped” nail.

Normal nail variant in infants, but corrects itself within the first few years of life.

Causes by iron deficiency anemia, hemochromatosis, Raynaud’s disease, SLE, trauma, occupational exposure of the hands to petroleum-based solvents, nail-patella syndrome

Onycholysis

Lifting of the nail plate from the nail bed. Causes:

Trauma Psoriasis Drug reactions (tetracycline) Bacterial/fungal/viral infection Contact dermatitis from using nail hardeners Thyroid disease (“Plummer’s nails”) Iron deficiency anemia Syphilis Eczema Porphyria cutanea tarda Amyloidosis, connective tissue disorders

Onycholysis

Causes Onychomycosis Chronic eczema Peripheral vascular disease Yellow nail syndrome Psoriasis Not cutting the nails, trauma

Trichophyton Rubrum most common dermatophyte

Toenails more commonly affected than fingernails and often associated with tinea pedis

Causes Age, M>F, immunosuppression, HIV, DM,

chronic trauma, PVD, hyperhydrosisUncommon in children

23% relapse rate w/ terbinafine Old age and slow nail growth Immunosuppression Reinfection from surrounding skin Preventing Relapse

Avoid barefeet in public places Keep feet dry Apply antifungal cream to feet weekly Apply antifungal powder or spray to shoes

weekly Discard old shoes

The nail becomes thin, rudimentary and smaller size congenital or acquired.

Causes: Lichen planus Epidermolysis bullosa Darier‘s disease Vascular disturbances Leprosy

Categories Derm conditions: Psoriasis oil spot Systemic drugs or ingestants: AZT,

Minocin, Chemotherapy drugs Systemic Disease: Mees Lines

(Leukonychia) Local agents: Cosmetics, physical agents

If the discoloration follows the shape of the lunula and effects multiple nails think of a systemic cause.

If the discoloration corresponds to the

shape of the proximal nail fold and effects only a few nails think of an external cause.

If scraping the nail surface or using acetone removes the color then the cause is a topical substance.

If the lunula is absent, consider anemia or malnutrition

A pyramidal lunula might indicate excessive manicure or trauma

A pale blue lunula suggests diabetes mellitus

If the lunula has red discoloration, consider the following causes among others: cardiovascular disease; collagen vascular disease; and hematologic malignancy.

Originates in matrix and involves nail plate

Causes Trauma Systemic disease Drugs Heredity Sporadic

Can be total, subtotal or partial (punctate or transverse)

Mee's lines

Transverse type of true leukonychia caused by systemic disease.

Clinical: Single or multiple transverse lines that involve multiple nails.

The pigment is in the nail plate. Causes: Arsenic poisoning, Hodgkin’s disease,

CHF, leprosy, malaria, chemotherapy, carbon monoxide poisoning, other systemic insults

Muehrcke's Lines

Confined to the nail bed. Will disappear when distal digit is squeezed.

Clinical: Double white transverse lines affecting numerous nails.

Causes: Chemotherapy and Hypoalbuminemia secondary to nephrotic syndrome, liver disease, or glomerulonephritis.

Terry’s Nails

Clinical: Proximal white nail with narrow distal pink or brown band (0.5 to 3mm)

The nail looks opaque and white, but the nail tip has a dark pink to brown band.

Causes: cirrhosis, CHF, DM, cancer, hyperthyroidism, malnutrition, ageing

Half and Half Nails

Clinical: Proximal half of nail plate is white & distal half is red brown.

Cause: Present in 9 to 15 % of chronic renal failure patients. (Lindsay's nails) — Look for an arc of brownish discoloration.

Splinter Hemorrhages

Longitudinal hemorrhagic streaks involving the nail bed.

Causes: Trauma (most common), Derm disease (psoriasis), Idiopathic, and Systemic disease (subacute bacterial endocarditis )

Diagnostic Pearls If multiple nails are involved simultaneously and they occur

near the lunula think of systemic disease. If one or a few nails are involved and they occur near the

end of the nail plate think of trauma

Causes: Anemia Renal failure Cirrhosis Diabetes mellitus Chemotherapy Hereditary (rare).

Causes: Polycythemia (dark) Systemic lupus erythematosus Carbon monoxide (cherry red) Angioma Malnutrition

Causes: Cardiovascular disease Diabetes mellitus Vitamin B12 deficiency Breast cancer Malignant melanoma Lichen planus Syphilis Topical agents, including hair dyes, solvents for

false nails, varnish, and formaldehyde (among many others)

Diabetes mellitus Amyloidosis Median/ulnar nerve injury Thermal injury Jaundice

Arrest in nail growth with yellow or green nails, absence of cuticle, thick nail plate. Usually all nails affected

Can indicate internal disorders long before other symptoms appear.

Associated with pulmonary disease (COPD, TB, asthma, chronic bronchitis), chronic lymphedema, and thyroid disease, diabetes, liver disorders.

Causes: Topical preparations, including

chlorophyll derivations, methyl green, and silver nitrate (among others)

Chronic Pseudomonas spp infection Trauma

Melanonychia

Longitudinal Pigmented Bands (LPB) Cause: Pigmented band appearing in the distal matrix and

extending to the tip of the nail. Clinical: Tan, brown or black longitudinal streaks within the

nail plate. May be single or multiple bands. Causes:

Melanocytic activation ▪ No increase in melanocyte number ▪ Responsible for 73% of single LPB in adults.

Melanocytic hyperplasia ▪ Increase in melanocyte number ▪ Responsible for 77% of single LPB in children

Common in darkly pigmented persons African Americans: 77% by age 20, 100%

by age 50 Asian: 10-20% Hispanic, Indian common Unusual in Caucasians Thumb & index finger most commonly

affected

Melanocyte activation Racial, pregnancy Trauma, post inflammatory (lichen

plannus, pustular psoriasis, onychomycosis, chronic radiodermatitis)

Drugs (doxyrubicin, 5-FU, AZT, psoralens) Laugler-Hunziker/Putz Jeger Syndromes Addison’s Disease HIV

Non-melanocytic tumors (Bowen’s Disease, Verrucae, Basal cell carcinoma, Subungual keratosis, Myxoid cyst)

Melanocyte hyperplasia

Nail matrix nevus

Nail matrix melanoma

Subungual Melanoma

Rare in caucasians 1 to 4% of all melanomas

African Americans 25% Asians 17 to 23%

Peak age 50 to 80 but can occur at any age Rare in children LPB is first sign in 38 to 76 % of nail melanoma

45-60% on hand 40%-55% on foot

Thumb, index finger, great toe most common sites

Develops in a single digit in adult life especially in 6th decade or later

Develops abruptly in previously normal nail

Becomes suddenly darker or widerPreceding history of digital trauma

Occurs as a single band in the thumb, index finger or great toe in a dark skinned patient

Demonstrates blurred lateral margin Occurs in a patient with a personal

history of melanoma Occurs in a patient with a family history

of melanoma Presence of partial or complete nail

dystrophy

Age: Peak incidence 5th to 7th decade Band: Brown – black band, Breadth > 3mm,

Border irregular/ blurred Change: Rapid change in growth and/or color or

lack of change: Failure of nail dystrophy to improve with adequate treatment

Digit involved: Thumb > great toe > index finger, Single > multiple digits, Dominant hand

Extension: Of pigment to proximal or lateral nail fold

Family or personal history: Previous melanoma or dysplastic nevus syndrome

Mass below nail with partial or complete nail destruction - 50%

Periungual infection/ulceration of nail bed/granulation tissue - 33%

Discoloration of nail area - 33% Amelanotic - 25% Some begin as LPB: 38% -76% Hutchinson's sign less frequent Frequent delay in diagnosis: Mistaken for

traumatic, infected, or inflamed lesion

Most patients present with late disease

5 year survival 16-61 % 25% nodal spread

25% of nail melanomas Misdiagnoses

Pyogenic granuloma Chronic granulation tissue Paronychia

Subungual Hematoma

Acute lesions are red and painful Older lesions are purple or black and nontender DDx: Melanoma is a concern especially in an

older patient A pigmented lesion will persist as the nail grows Hemorrhage will be replaced proximally by a normal nail

plate as the nail grows Melanomas can produce hemorrhage Biopsy if unsure or concerned Tx: If painful, decompress an acute lesion

Mucous or Myxoid Cyst

Smooth flesh colored semi-translucent nodule between the DIP joint & proximal nail fold

Contains a viscous clear fluid Exerts pressure on the matrix resulting in a

longitudinal groove Usually associated with osteoarthritis & may

connect with the joint space TX: A cyst that does not connect with the joint

space, I&D and intralesional steroids or cryotherapy

A cyst that connects with joint space may require surgical removal

Pyogenic Granuloma

Clinical: Over growth of vascular tissue involving the paronychia. Bleeds easily.

Causes: Trauma, infection, ingrown nail

Tx: Biopsy to rule out amelanotic melanoma

Treat underlying cause

Common in males on the fingernails. Causes: UV light, HPV, chronic

infection, trauma, X ray exposure. Clinical: Long standing scaly or wart

like growth involving the lateral nail fold. May see onycholysis & nail plate deformity.

Biopsy all recalcitrant warts in older patients.

Tx: Mohs micrographic surgery.

All have nail findings that for the most part are nonspecific.

Periungual erythema and telangiectasias are specific & can be an early finding that may help make the diagnosis in difficult cases.

Causes: Atopic dermatitis, dyshidrotic eczema, irritant or contact dermatitis e.g. acrylates in sculptured nails.

Clinical: Paronychium -Acute or chronic paronychia, Beau's lines, and pits. Hyponychium -Subungual hyperkeratosis onycolysis & finger tip scaling.

Tx: Remove cause & medium strength topical steroids.

Inflammation of the nail folds, which appear red, swollen and tender.

Non bacterial causes: contact irritant dermatitis, dyshidrotic eczema, & drugs, fungal

Acute bacterial paronychia most common infection of the hand. (Staph, strep & pseudomonas)

Caused by aggressive manicuring or nail biting Tx: I&D when necessary and culture when possible Antistaphylococcal antibiotic for 7 to 10 days. For unresponsive cases r/oosteomyelitis and Bx to

r/o malignancy.

Inflammation involving the nail folds lasting > 6 wks.

Causes: Aggressive manicuring, chronic exposure to water, contact irritants, & in children finger sucking

Bakers, bartenders, waitresses, food handlers, maids, mothers with children

Candida & bacteria are secondarily present Chronic swelling of the nail folds & loss of the

cuticle Tx: Eliminate cause & minimize water contact. Mid

or high potency topical steroids & ciclopirox ( Loprox suspension).

Fawcett L, Linford S. Nail Abnormalities: Clues to Systemic Disease. American Family Physician. March 15, 2004.

http://hsc.unm.edu/cme/2008Web/Dermatology/nails%202008.pdf

Williams M. Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients. Medscape. 11/23/2009.