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__NOTOC__
{{DiseaseDisorder infobox |
  Name          = Nail disease |
  ICD10          = {{ICD10|L|60||l|60}} |
  ICD9          = {{ICD9|703}} |
  ICDO          = |
  Image          = ONYCHIA1.JPG |
  Caption        = Onychia without [[granuloma]] |
  OMIM          = |
  MedlinePlus    = 003247 |
  eMedicineSubj  = |
  eMedicineTopic = |
  DiseasesDB    = 23092 |
}}
{{SI}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{SK}} nail abnormality, nail disorders, nail signs
==Overview==
'''Nail diseases''' are distinct from diseases of the skin. Although [[nail (anatomy)|nail]]s are a skin appendage, they have their own signs and symptoms which may relate to other medical conditions. Nail conditions that show signs of [[infection]] or [[inflammation]] require medical assistance and cannot be treated at a beauty parlor. [[Deformity]] or [[disease]] of the nails may be referred to as '''onychosis'''.


==Classification Scheme==
==Classification Scheme==
Line 50: Line 29:


===[[Subungual hyperkeratosis]]===
===[[Subungual hyperkeratosis]]===
<div align="left">
<gallery heights="175" widths="175">
Image:Fingernail label.jpg|A normal nail
Image:Fingernails1.JPG|Normal fingernails
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
Image:Toes.jpg|Normal toenails
Image:HEMORRHAGESUBUNG1.JPG|Subungual hematoma (mild)
</gallery>
</div>
==Diseases==
*''Onychia'' is an inflammation of the matrix (surrounding tissue) of the nail with formation of [[pus]] and shedding of the nail.  Onychia results from the introduction of microscopic [[pathogen]]s through small wounds.
*''[[Ingrown nail|Onychocryptosis]]'', commonly known as "ingrown nails" (''unguis incarnatus''), can affect either the fingers or the toes.  In this condition, the nail cuts into one or both sides of the nail bed, resulting in inflammation and possibly infection. The relative rarity of this condition in the fingers suggests that pressure from the ground or shoe against the toe is a prime factor. The movements involved in [[walking]] or other physical disturbances can contribute to the problem.  Mild onychocryptosis, particularly in the absence of infection, can be treated by trimming and rounding the nail.  More advanced cases, which usually include infection, are treated by surgically excising the ingrowing portion of the nail down to its bony origin and thermally or chemically [[cauterizing]] the matrix, or 'root', to prevent recurrence.  This surgery is called matrixectomy. The best results are achieved by cauterizing the matrix with [[phenol]]. Another, much less effective, treatment is [[excision]] of the matrix, sometimes called a 'cold steel procedure'.
*''Onychodystrophy'' is a deformation of the nails that can result from cancer chemotherapy which includes bleomycin, hydroxyurea, or 5-fluorouracil. It can include discoloration of the nail, or dyschromia.
*''[[Onychogryposis]]'', also called "ram's-horn nail", is a thickening and increase in curvature of the nail.  It is usually the result of injury to the matrix.  It may be partially [[hereditary]] and can also occur as a result of long-term neglect.  It is most commonly seen in the great toe but may be seen in other toes as well as the fingernails.  An affected nail has many grooves and ridges, is brownish in color, and grows more quickly on one side than on the other.  The thick curved nail is difficult to cut, and often remains untrimmed, exacerbating the problem.
*''Onycholysis'' is a loosening of the exposed portion of the nail from the nail bed, usually beginning at the free edge and continuing to the [[lunula (anatomy)|lunula]].  It is frequently associated with an internal disorder, trauma, infection, nail fungi, allergy to nail enhancement products, or side effects of drugs.
*''Onychomadesis'' is the separation and falling off of a nail from the nail bed.  Common causes include localized infection, minor injury to the matrix bed, or severe systemic illness. It is sometimes a side effect of [[chemotherapy]] or [[x-ray]] treatments for [[cancer]].  A new nail plate will form once the cause of the disease is removed.
*''[[Onychomycosis]]'', also known as [[tinea|''tinea unguium'']], is a contagious infection of the nail caused by the same fungal organisms which cause [[ringworm]] of the skin (''Trichophyton rubrum'' or ''T. mentagrophytes'', rarely other trichophyton species or ''Epidermophyton floccosum'' <ref name="mycology">{{cite book |last= Hall |first= John C. |editor= John C. Hall |title= Sauer's Manual of Skin Diseases |edition= 9th edition |year= 2006 |publisher= Lippincott Williams & Wilkins |location= Philadelphia |isbn= 0-7817-2947-5|pages= 244=266 |chapter= 25. Dermatologic mycology.}}</ref>). It can result in discoloration, thickening, chalkiness, or crumbling of the nails and is often treated by powerful oral medications which, rarely, can cause severe side effects including liver failure. Mild onychomycosis sometimes responds to a combination of topical antifungal medication, sometimes applied as special medicinal nail lacquer, and periodic filing of the nail surface. For advanced onychomycosis, especially if more than one nail is infected, systemic medication (pills) is preferred. Home remedies are often used, although their effectiveness is disputed. In a study at the University of Rochester [[tea tree oil]] applied twice daily in conjunction with [[debridement]] was found to be an appropriate initial treatment strategy, equally effective to topical use of [[clotrimazole]]<ref name="scratch">[http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=8195735&dopt=AbstractPlus].</ref>.  Another procedure is to apply two drops of distilled white vinegar to the nail base, or, additionally, nail plate and under the nail, two or three times daily for approximately six months or until the fungus is gone. This treatment is very effective, due to the vinegar's acidity, if followed consistently.
*''Onychophosis'' is a growth of horny [[epithelium]] in the nail.
*''Onychoptosis'' is the periodic shedding of one or more nails, in whole or part. This condition may follow certain diseases such as [[syphilis]], or can result from [[fever]], [[Physical trauma|trauma]], systemic upsets or adverse reaction to drugs.
*''[[Paronychia]]'' is a bacterial or fungal infection where the nail and skin meet. {{main|Paronychia}}
*''[[Koilonychia]]'' is when the nail curves upwards (becomes spoon-shaped) due to an [[iron deficiency]].  The normal process of change is: brittle nails, straight nails, spoon-shaped nails.
*''[[Subungual hematoma]]'' occurs when trauma to the nail results in a collection of blood, or [[hematoma]], under the nail.  It may result from an acute injury or from repeated minor trauma such as running in undersized shoes.  Acute subungual hematomas are quite painful, and are usually treated by releasing the blood by creating a small hole in the nail.  Drilling and thermal cautery (melting) are common methods for creating the hole.  Thermal cautery is not used on acrylic nails because they are flammable.
==Associated Conditions with Nail Changes==
Nail inspection can give a great deal of information about the internal working of the body as well, and like tongue or [[Iris (anatomy)|iris]] inspection, has a long history of diagnostic use in traditional medical practices such as [[Chinese medicine]].
===Pliability:===
*Brittleness is associated with iron deficiency, thyroid problems,<ref>http://www.bhcs.com/healthinformation/baylorhealthmagazine/2005/nov/AS_thyroid.htm</ref> impaired kidney function, circulation problems, and biotin deficiency<ref name="scratch" />
*Splitting and fraying are associated with psoriasis and deficiencies of folic acid, protein and Vitamin C.
*Unusual thickness is associated with circulation problems.
*Thinning nails and itchy skin are associated with [[lichen planus]]<ref name="jewel">Judith Cobb, [http://www.nspforum.com/faq/index.cgi?read=929 Fingernails, Jewels or Tools]? ''Nature's Field'' - Nail diagnosis]</ref>.
===Shape and texture:===
*Clubbing, or nails that curve down around the fingertips with nailbeds that bulge is associated with oxygen deprivation and lung, heart, or liver disease.
*Spooning, or nails that grow upwards is associated with iron or B12 deficiency.
*Flatness can indicate a B12 vitamin deficiency<ref name="jewel" /> or [[Raynaud's disease]]<ref name="tool">Mariann Cade, [http://www.nspforum.com/faq/bbs.cgi?read=1191 Fingernails - Diagnostic Tool]</ref>
*Pitting of the nails is associated with [[Psoriasis]].
*Ridges across the nail indicate stress.
*[[Beau's lines]] across the nail are associated with many serious conditions.
*Ridges along the nail are associated with arthritis<ref name="scratch" />.
*Grooves  along the nail are associated with kidney disorders, aging, and iron deficiency<ref name="scratch" />.
*Beading is associated with [[rheumatoid arthritis]]<ref name="scratch" />.
*Nails that resemble hammered brass are associated with (or portend) [[hair loss]]<ref name="jewel" />.
*Short small beds are associated with heart disease.
===Coloration of the nail bed:===
*[[Mee's lines]] are associated with [[arsenic]] or [[thallium]] [[poison]]ing, and renal failure.
*White lines across the nail are associated with heart disease, liver disease, or a history of a recent high fever<ref name="jewel" />.
*[[Terry's nails|Opaque white nails with a dark band at the fingertip]] are associated with cancer, cirrhosis, congestive heart failure, diabetes and aging<ref name="jewel" />.
*Paleness or whitening is associated with liver or kidney disease and anemia<ref name="jewel" />.
*Yellowing of the nail bed is associated with chronic bronchitis, lymphatic problems, diabetes, and liver disorders.
*Brown or copper nail beds are associated with arsenic or copper poisoning, and [[Onychomycosis|local fungal infection]].
*Grey nail beds are associated with [[arthritis]], [[edema]], [[malnutrition]], post-[[Surgery|operative]] effects, [[glaucoma]] and [[cardio]]-[[pulmonary]] disease.
*Redness is associated with heart conditions.
*Dark nails are associated with B12 deficiency.
*Stains of the nail plate (not the nail bed) are associated with nail polish<ref name="scratch" />, smoking, and henna use.
===Markings:===
*Pink and white nails are associated with kidney disease<ref name="jewel" />.
*[[Muehrcke's lines]] are white lines across the nail associated with [[hypoalbuminemia]].
*Red skin at the base of the nail is associated with connective tissue disorders<ref name="jewel" />.
*Blue lunulae are associated with silver poisoning or lung disorder<ref name="jewel" />.
*Blue nail beds are (much like blue skin) associated with poor oxygenation of the blood ([[asthma]], [[emphysema]], etc)<ref name="jewel" />.
*[[Leukonychia|Small white patches]] are associated with zinc or calcium deficiency or malabsorption, parasites, or local injury<ref name="tool" />.
*Receded lunulae (fewer than 8) are associated with poor circulation<ref name="tool" />, shallow breathing habits or thyroid mysfunction<ref name="jewel" />.
*Large lunulae (more than 25% of the thumb nail) are associated with high blood pressure.
== Diagnosis ==
=== History and Symptoms ===
* History of [[psoriasis]]
* Family history
* Occupational history
* Hobbies
=== Physical Examination ===
* Complete skin exam
=== Laboratory Studies ===
* Periodic Acid-Schiff (PAS)
* Fungal cultures
* Bacterial cultures
=== Other Diagnostic Studies ===
* [[Nail matrix]] [[biopsy]]
* Possible dermatology referral
== Differential Diagnosis of Causes of Nail changes==
=== Beau's Lines ===
''Transverse furrows, sign of a previous arrest in the growth process''
*[[Coronary occlusion]]
*[[Delirium]]
*[[Depression]]
*[[Gout]]
*[[Malnutrition]]
*[[Reiter's Disease]]
*[[infectious disease|Severe infectious disease]]
*[[Shock]]
*[[Surgery]]
*[[Toxin]]s
*[[Trauma]]
*[[nail matrix|Traumatic damage to nail matrix]]
=== Blue discoloration ===
*[[Argyria]]
*[[Dapsone|DADPS]]
=== Brown-black discoloration ===
*[[Acral lentiginous melanoma]]
*[[Alcaptonuria]]
*[[Hematoma]]
*[[Mole]]s
*[[Ochronosis]]
== Green-black discoloration ==
*[[infection]] with [[pseudomonas aeruginosa]]
=== Half and Half Nails ===
''White (proximal) and brown (distal) reversible coloration of the nail''
*[[Uremia]]
=== Hippocratic Nails ===
''Large, curved nails that usually occur in conjunction with clubbing''
*[[Arteriovenous fistula|Arteriovenous shunts]]
*[[Biliary Cirrhosis]]
*[[Bronchiectasis]]
*[[Bronchial carcinoma]]
*[[Cerebral contusion|Cerebrovascular trauma]]
*[[Congenital heart disease|Cyanotic congenital heart disease]]
*[[Crohn's Disease]]
*[[Emphysema]]
*[[Heart Failure]]
*[[Infectious Endocarditis]]
*[[Hepatocellular carcinoma|Liver Tumors]]
*[[Lung Abscess]]
*[[Mesothelioma]]
*[[Pachydermoperiostosis]]
*[[Pulmonary artery]] [[sclerosis]]
*[[Pulmonary fibrosis]]
*[[metastase|Pulmonary metastases]]
*[[Silicosis]]
*[[Sprue]]
*[[Tuberculosis]]
*[[Ulcerative Colitis]]
=== [[Koilonychia]] ===
''A malformation of the nails which the outer surface is concave''
*[[Addison's Disease]]
*[[Cushing's Disease]]
*[[Diabetes Mellitus]]
*[[Grave's Disease]]
*[[Hereditary]]
*[[Hypochromic anemia]]
*[[Iron deficiency]]
*[[Malnutrition]]
*[[Multiple Myeloma]]
*[[Pellagra]]
*[[Raynaud's disease]]
*[[Vitamin B12 Deficiency]]
=== [[Leukonychia]] ===
''White coloration of nails''
*[[Anemia]]
*[[Heart disease|Cardiac Diseases]]
*[[Cirrhosis]]
*[[Darier's disease]]
*[[Fever]]
*[[Hypoalbuminemia]]
*[[Mycosis]]
*[[Nitrate]] [[solution]]
*[[Silver]] [[solution]]
*[[Noxa]]
*[[Trauma]]
=== Mee's Lines ===
''Horizontal white bands of the nails''
*[[Drug]]s/[[Toxin]]s
*[[Fluorosis]]
*Occasionally occurs in [[leprosy]]
===Onychogryphosis ===
''Brittle, Split nails''
*[[Anemia]]
*Chronic [[chemical]] damage
*[[Lichen|Lichen ruber]]
*[[Thyroid Disease]]
=== Onchodystrophy ===
''Deformed, brittle, rough, discolored nails''
*[[Eczema]]
*[[Fungal infection]]
*[[Psoriasis]]
=== Onycholysis ===
''Painless loss of the nail''
*[[ICD-10 Chapter IX: Diseases of the circulatory system|Circulatory system diseases]]
*[[Diabetes Insipidus]]
*[[Diabetes Mellitus]]
*[[Drug]]s
*[[Eczema]]
*[[Hemangioma]] under the nail
*[[Onychomycosis]]
*[[Psoriasis]]
*[[Reiter's Disease]]
*[[Thyroid Disease]]
*[[Tumor]]
=== Paronychia ===
''Inflammation of the nail bed''
*[[Bacteria]]l
*[[Candida]]
*[[Syphillis]]
=== Pitted Nails ===
''Pinpoint depressions in the nails''
*[[Alopecia areata]]
*[[Lichen|Lichen ruber]]
*[[Lupus erythematosus]]
*[[Neurodermatitis]]
*[[Psoriasis]]
*[[Rheumatic Fever]]
=== Yellow nails ===
''Yellow-greenish discoloration of the nails (some or all) with subsequent [[onycholysis]]''
*[[Congenital]] [[hypoplasia]] / [[dysplasia]] of peripheral [[lymph vessel]]s
*Diseases of the [[bronchial tube]]s
*Diseases of the [[paranasal sinus]]es
*Smoker's fingers
==Pathological Findings==
[http://www.peir.net Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]
<div align="left">
<gallery heights="175" widths="175">
image:Acrocyanosis.jpg|[[Acrocyanosis]]: Gross, an excellent example of cyanotic nail beds.
image:Trophic changes.jpg|Trophic Changes: Gross natural color distorted nails and thick skin typical of chronic ischemia
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Halfandhalf.jpg|[[Renal failure]], chronic with nail changes; half and half nails. Left hand more typical. Unusual asymmetrical
image:Hydroxyurea nails.jpg|[[Hydroxyurea]] Nails; Nail changes associated with Hydroxyurea therapy in a patient with essential thrombocythemia.
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Brown banding.jpg|Nail disease, brown banding
image:Secondary to psoriasis.jpg|Nail disease, secondary to [[psoriasis]]
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Paronychia candida.jpg|[[Paronychia]] due to [[Candida]]; nail diseases
image:White banding.jpg|Nail disease; white banding
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Bowens carcinoma.jpg|Nail: Bowen's carcinoma
image:Scleroderma nail.jpg|Nail changes in [[Scleroderma]]. Posterior nail fold.
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Subungual melanoma.jpg|This is a subungual radial growth phase of acral-lentiginous type with two amelanotic vertical growth phase tumor nodules. Radial growth phase is just beginning to grow onto the cuticle of the nail, displaying a subtle example of "Hutchinson's sign."
image:Subungual fibroma.jpg|[[Tuberous sclerosis]]; Subungual fibroma; Beneath the Left Index Nail
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Periungual fibroma.jpg|[[Tuberous sclerosis]], Periungual Fibroma; Lateral Side of Left Great Toe Nail
image:Trauma.Nail.jpg|Traumatic nail changes
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Secondary aterosclerotic changes.Nail.jpg|Secondary atherosclerosis caused nail disorders.
image:Onykomycosis.Nail.jpg|Onychomycosis
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Beaus groove.Nail.jpg|Beau's groove
image:Clubbing.Nail.jpg|Clubbing
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Splitting.Nail.jpg|Splitting
image:Secondary to warts.Nail.jpg|Nail changes secondary to wart.
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Onycholysis.Nail.jpg|Onycholysis
image:Whitlow.Herpetic disease.Nail.jpg|Herpes simplex caused nail disease.
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
image:Lichen planus.Nail.jpg|Nail changes is Lichen planus
image:Skin carcinoma.Nail.jpg|Skin carcinoma
</gallery>
</div>
== Treatment ==
=== Acute Pharmacotherapies ===
* Systemic antifungals
* Intralesional steroids
* Topical paint-on ciclopirox
* Systemic antipsoriatic therapies
== References ==
{{Reflist|2}}
==See also==
* [[Leukonychia]]
* [[Mee's lines]]
* [[Beau's lines]]
* [[Occupational hazards associated with exposure to human nail dust]]
== External links ==
* [http://www.mckinley.uiuc.edu/handouts/ingrown%5Ftoenail/ingrown%5Ftoenail.html Ingrown Toenail] - explanation covering causes, treatment, and prevention (with diagram)
* [http://www.lib.uiowa.edu/hardin/md/nailspictures.html Links to pictures of Nail Diseases (Hardin MD/Univ of Iowa)]
*[http://www.associatedcontent.com/article/38824/how_fingernail_fungus_spreads_and_how.html How Fingernail Fungus Spreads, and How to Treat It] a practical guide for the layman.
*[http://www.aafp.org/afp/20040315/1417.html Nail Abnormalities: Clues to Systemic Disease]
{{Diseases of the skin and subcutaneous tissue}}
[[Category:Signs and symptoms]]
[[Category:Dermatology]]
[[Category:Primary care]]
[[Category:Physical examination]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Revision as of 15:48, 30 July 2012

Classification Scheme

Acrocyanosis

Beau lines

Digital clubbing

Koilonychia

Nail discoloration

Nail pitting

Onycholysis

Onychorrhexis

Pachyonychia

Paronychia

Platonychia

Ridged nails

Splinter hemorrhages

Subungual hyperkeratosis

  • A normal nail

    A normal nail

  • Normal fingernails

    Normal fingernails


  • Normal toenails

    Normal toenails

  • Subungual hematoma (mild)

    Subungual hematoma (mild)

Diseases

  • Onychia is an inflammation of the matrix (surrounding tissue) of the nail with formation of pus and shedding of the nail. Onychia results from the introduction of microscopic pathogens through small wounds.
  • Onychocryptosis, commonly known as "ingrown nails" (unguis incarnatus), can affect either the fingers or the toes. In this condition, the nail cuts into one or both sides of the nail bed, resulting in inflammation and possibly infection. The relative rarity of this condition in the fingers suggests that pressure from the ground or shoe against the toe is a prime factor. The movements involved in walking or other physical disturbances can contribute to the problem. Mild onychocryptosis, particularly in the absence of infection, can be treated by trimming and rounding the nail. More advanced cases, which usually include infection, are treated by surgically excising the ingrowing portion of the nail down to its bony origin and thermally or chemically cauterizing the matrix, or 'root', to prevent recurrence. This surgery is called matrixectomy. The best results are achieved by cauterizing the matrix with phenol. Another, much less effective, treatment is excision of the matrix, sometimes called a 'cold steel procedure'.
  • Onychodystrophy is a deformation of the nails that can result from cancer chemotherapy which includes bleomycin, hydroxyurea, or 5-fluorouracil. It can include discoloration of the nail, or dyschromia.
  • Onychogryposis, also called "ram's-horn nail", is a thickening and increase in curvature of the nail. It is usually the result of injury to the matrix. It may be partially hereditary and can also occur as a result of long-term neglect. It is most commonly seen in the great toe but may be seen in other toes as well as the fingernails. An affected nail has many grooves and ridges, is brownish in color, and grows more quickly on one side than on the other. The thick curved nail is difficult to cut, and often remains untrimmed, exacerbating the problem.
  • Onycholysis is a loosening of the exposed portion of the nail from the nail bed, usually beginning at the free edge and continuing to the lunula. It is frequently associated with an internal disorder, trauma, infection, nail fungi, allergy to nail enhancement products, or side effects of drugs.
  • Onychomadesis is the separation and falling off of a nail from the nail bed. Common causes include localized infection, minor injury to the matrix bed, or severe systemic illness. It is sometimes a side effect of chemotherapy or x-ray treatments for cancer. A new nail plate will form once the cause of the disease is removed.
  • Onychomycosis, also known as tinea unguium, is a contagious infection of the nail caused by the same fungal organisms which cause ringworm of the skin (Trichophyton rubrum or T. mentagrophytes, rarely other trichophyton species or Epidermophyton floccosum [1]). It can result in discoloration, thickening, chalkiness, or crumbling of the nails and is often treated by powerful oral medications which, rarely, can cause severe side effects including liver failure. Mild onychomycosis sometimes responds to a combination of topical antifungal medication, sometimes applied as special medicinal nail lacquer, and periodic filing of the nail surface. For advanced onychomycosis, especially if more than one nail is infected, systemic medication (pills) is preferred. Home remedies are often used, although their effectiveness is disputed. In a study at the University of Rochester tea tree oil applied twice daily in conjunction with debridement was found to be an appropriate initial treatment strategy, equally effective to topical use of clotrimazole[2]. Another procedure is to apply two drops of distilled white vinegar to the nail base, or, additionally, nail plate and under the nail, two or three times daily for approximately six months or until the fungus is gone. This treatment is very effective, due to the vinegar's acidity, if followed consistently.
  • Onychophosis is a growth of horny epithelium in the nail.
  • Onychoptosis is the periodic shedding of one or more nails, in whole or part. This condition may follow certain diseases such as syphilis, or can result from fever, trauma, systemic upsets or adverse reaction to drugs.
  • Paronychia is a bacterial or fungal infection where the nail and skin meet.
    Main article: Paronychia
  • Koilonychia is when the nail curves upwards (becomes spoon-shaped) due to an iron deficiency. The normal process of change is: brittle nails, straight nails, spoon-shaped nails.
  • Subungual hematoma occurs when trauma to the nail results in a collection of blood, or hematoma, under the nail. It may result from an acute injury or from repeated minor trauma such as running in undersized shoes. Acute subungual hematomas are quite painful, and are usually treated by releasing the blood by creating a small hole in the nail. Drilling and thermal cautery (melting) are common methods for creating the hole. Thermal cautery is not used on acrylic nails because they are flammable.

Associated Conditions with Nail Changes

Nail inspection can give a great deal of information about the internal working of the body as well, and like tongue or iris inspection, has a long history of diagnostic use in traditional medical practices such as Chinese medicine.

Pliability:

  • Brittleness is associated with iron deficiency, thyroid problems,[3] impaired kidney function, circulation problems, and biotin deficiency[2]
  • Splitting and fraying are associated with psoriasis and deficiencies of folic acid, protein and Vitamin C.
  • Unusual thickness is associated with circulation problems.
  • Thinning nails and itchy skin are associated with lichen planus[4].

Shape and texture:

  • Clubbing, or nails that curve down around the fingertips with nailbeds that bulge is associated with oxygen deprivation and lung, heart, or liver disease.
  • Spooning, or nails that grow upwards is associated with iron or B12 deficiency.
  • Flatness can indicate a B12 vitamin deficiency[4] or Raynaud's disease[5]
  • Pitting of the nails is associated with Psoriasis.
  • Ridges across the nail indicate stress.
  • Beau's lines across the nail are associated with many serious conditions.
  • Ridges along the nail are associated with arthritis[2].
  • Grooves along the nail are associated with kidney disorders, aging, and iron deficiency[2].
  • Beading is associated with rheumatoid arthritis[2].
  • Nails that resemble hammered brass are associated with (or portend) hair loss[4].
  • Short small beds are associated with heart disease.

Coloration of the nail bed:

  • Mee's lines are associated with arsenic or thallium poisoning, and renal failure.
  • White lines across the nail are associated with heart disease, liver disease, or a history of a recent high fever[4].
  • Opaque white nails with a dark band at the fingertip are associated with cancer, cirrhosis, congestive heart failure, diabetes and aging[4].
  • Paleness or whitening is associated with liver or kidney disease and anemia[4].
  • Yellowing of the nail bed is associated with chronic bronchitis, lymphatic problems, diabetes, and liver disorders.
  • Brown or copper nail beds are associated with arsenic or copper poisoning, and local fungal infection.
  • Grey nail beds are associated with arthritis, edema, malnutrition, post-operative effects, glaucoma and cardio-pulmonary disease.
  • Redness is associated with heart conditions.
  • Dark nails are associated with B12 deficiency.
  • Stains of the nail plate (not the nail bed) are associated with nail polish[2], smoking, and henna use.

Markings:

  • Pink and white nails are associated with kidney disease[4].
  • Muehrcke's lines are white lines across the nail associated with hypoalbuminemia.
  • Red skin at the base of the nail is associated with connective tissue disorders[4].
  • Blue lunulae are associated with silver poisoning or lung disorder[4].
  • Blue nail beds are (much like blue skin) associated with poor oxygenation of the blood (asthma, emphysema, etc)[4].
  • Small white patches are associated with zinc or calcium deficiency or malabsorption, parasites, or local injury[5].
  • Receded lunulae (fewer than 8) are associated with poor circulation[5], shallow breathing habits or thyroid mysfunction[4].
  • Large lunulae (more than 25% of the thumb nail) are associated with high blood pressure.

Diagnosis

History and Symptoms

  • History of psoriasis
  • Family history
  • Occupational history
  • Hobbies

Physical Examination

  • Complete skin exam

Laboratory Studies

  • Periodic Acid-Schiff (PAS)
  • Fungal cultures
  • Bacterial cultures

Other Diagnostic Studies

Differential Diagnosis of Causes of Nail changes

Beau's Lines

Transverse furrows, sign of a previous arrest in the growth process

Blue discoloration

Brown-black discoloration

Green-black discoloration

Half and Half Nails

White (proximal) and brown (distal) reversible coloration of the nail

Hippocratic Nails

Large, curved nails that usually occur in conjunction with clubbing

Koilonychia

A malformation of the nails which the outer surface is concave

Leukonychia

White coloration of nails

Mee's Lines

Horizontal white bands of the nails

Onychogryphosis

Brittle, Split nails

Onchodystrophy

Deformed, brittle, rough, discolored nails

Onycholysis

Painless loss of the nail

Paronychia

Inflammation of the nail bed

Pitted Nails

Pinpoint depressions in the nails

Yellow nails

Yellow-greenish discoloration of the nails (some or all) with subsequent onycholysis

Pathological Findings

Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

  • Acrocyanosis: Gross, an excellent example of cyanotic nail beds.

    Acrocyanosis: Gross, an excellent example of cyanotic nail beds.

  • Trophic Changes: Gross natural color distorted nails and thick skin typical of chronic ischemia

    Trophic Changes: Gross natural color distorted nails and thick skin typical of chronic ischemia

  • Renal failure, chronic with nail changes; half and half nails. Left hand more typical. Unusual asymmetrical

    Renal failure, chronic with nail changes; half and half nails. Left hand more typical. Unusual asymmetrical

  • Hydroxyurea Nails; Nail changes associated with Hydroxyurea therapy in a patient with essential thrombocythemia.

    Hydroxyurea Nails; Nail changes associated with Hydroxyurea therapy in a patient with essential thrombocythemia.

  • Nail disease, brown banding

    Nail disease, brown banding

  • Nail disease, secondary to psoriasis

    Nail disease, secondary to psoriasis

  • Nail: Bowen's carcinoma

    Nail: Bowen's carcinoma

  • Nail changes in Scleroderma. Posterior nail fold.

    Nail changes in Scleroderma. Posterior nail fold.

  • This is a subungual radial growth phase of acral-lentiginous type with two amelanotic vertical growth phase tumor nodules. Radial growth phase is just beginning to grow onto the cuticle of the nail, displaying a subtle example of "Hutchinson's sign."

    This is a subungual radial growth phase of acral-lentiginous type with two amelanotic vertical growth phase tumor nodules. Radial growth phase is just beginning to grow onto the cuticle of the nail, displaying a subtle example of "Hutchinson's sign."

  • Tuberous sclerosis; Subungual fibroma; Beneath the Left Index Nail

    Tuberous sclerosis; Subungual fibroma; Beneath the Left Index Nail

  • Tuberous sclerosis, Periungual Fibroma; Lateral Side of Left Great Toe Nail

    Tuberous sclerosis, Periungual Fibroma; Lateral Side of Left Great Toe Nail

  • Traumatic nail changes

    Traumatic nail changes

  • Secondary atherosclerosis caused nail disorders.

    Secondary atherosclerosis caused nail disorders.

  • Onychomycosis

    Onychomycosis

  • Beau's groove

    Beau's groove

  • Clubbing

    Clubbing

  • Splitting

    Splitting

  • Nail changes secondary to wart.

    Nail changes secondary to wart.

  • Onycholysis

    Onycholysis

  • Herpes simplex caused nail disease.

    Herpes simplex caused nail disease.

  • Nail changes is Lichen planus

    Nail changes is Lichen planus

  • Skin carcinoma

    Skin carcinoma

Treatment

Acute Pharmacotherapies

  • Systemic antifungals
  • Intralesional steroids
  • Topical paint-on ciclopirox
  • Systemic antipsoriatic therapies

References

  1. ↑ Hall, John C. (2006). "25. Dermatologic mycology.". In John C. Hall. Sauer's Manual of Skin Diseases (9th edition ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 244=266. ISBN 0-7817-2947-5.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 [1].
  3. ↑ http://www.bhcs.com/healthinformation/baylorhealthmagazine/2005/nov/AS_thyroid.htm
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Judith Cobb, Fingernails, Jewels or Tools? Nature's Field - Nail diagnosis]
  5. ↑ 5.0 5.1 5.2 Mariann Cade, Fingernails - Diagnostic Tool

See also

External links


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