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15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023
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Clubbing of the fingernails is shown. Image from Nguyen VH. Case Rep Med. 2011;2011:126209. [Open access.] PMID: 22013451, PMCID: PMC3195534. [Creative Commons Attribution License 3.0 Unported (CC by 3.0).]
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Nail Clubbing
From possible malignancy to nutritional status, a significant amount of information pertaining to a patient's overall health can be obtained by examining the fingernails and/or toenails.[1]
Although abnormalities of the nail are often caused by skin disease and infection, they may also indicate more general medical conditions. Careful examination can help the clinician to detect several general and specific pathologic indicators.
The above image shows fingernail clubbing. Which of the following conditions can be associated with this?
The Lovibond angle is shown. Adapted image from Wikimedia Commons | Jfdwolff (retouched by Laogooli). [CC Attribution-ShareAlike 3.0 Unported License (CC by-SA 3.0.)].
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Answer: D. Hamman-Rich syndrome (acute interstitial pneumonitis)
Nail clubbing is associated with various underlying pulmonary and cardiovascular disorders, as well as with neoplastic, infectious, hepatobiliary, mediastinal, endocrine, and gastrointestinal diseases.[2,3] Nail clubbing occurs when the angle made by the proximal nail fold and the nail plate, termed the Lovibond angle, is greater than 180° (the Lovibond angle of normal nails is generally <165°).[4] Hamman-Rich syndrome, or acute interstitial pneumonitis, is a form of idiopathic interstitial pneumonia that is characterized by inflammation of the lung interstitium.[5] With advanced interstitial lung diseases, digital clubbing and signs of right heart failure may appear.[6]
Image courtesy of Medscape | Antonella Tosti, MD.
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Onychomycosis
Fungal infections of the fingernails and toenails (onychomycosis) (shown) can be difficult to treat, and recurrences are common. In general, oral terbinafine and itraconazole are first-line agents for managing onychomycosis because of their deep-penetrating effects on the nail matrix and nail bed.[7,8]
Fingernails lacking a lunula are shown. Image from Gahalaut P, Mishra N, Chauhan S, Ali MM, Rastogi MK, Thakur R. ISRN Dermatol. 2014;2014:271230. [Open access.] PMID: 24701356, PMCID: PMC3950909. [CC by 3.0.]
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Anolunula
Abnormalities of the lunula are common and may lead clinicians down varied diagnostic paths. Absence of the lunula (anolunula) of the thumb should prompt investigation for anemia or malnutrition.[1,9] However, this also may be a normal finding. Anolunula of other digits is nonspecific.
A pyramidal lunula may be a sign of excessive manicure or trauma.[1] A pale blue lunula may indicate diabetes mellitus, whereas a red discoloration of the lunula may signify cardiovascular disease, collagen vascular disease, hematologic malignancy, or another serious diagnosis.[1]
Lymphedema is shown in the top left image. Yellow nail syndrome is shown in the top middle images. Bronchiectasis is shown in the bottom left image. Koilonychia is shown in the image on the right. Left images from OpenStax | Herbert L Fred, MD, Hendrik A van Dijk; right image courtesy of Medscape. [CC by 4.0.]
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Yellow Nail Syndrome
Yellow nail syndrome is characterized by yellow nails that lack a cuticle, grow slowly, and are loose or detached (onycholysis).[10,11] This condition most commonly is associated with lung disorders (bronchiectasis) and with lymphedema,[10,11] but yellow nails can also be suggestive of diabetes mellitus, amyloidosis, median/ulnar nerve injury, thermal injury, or jaundice.
Which of the following statements about the nail shape shown in the right image is correct?
It is not common in childhood.
It can be associated with iron deficiency anemia.
It can be associated with ingrown nails.
It is associated with psoriasis.
It is due to a nail tumor with psoriasis.
Image courtesy of Medscape.
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Koilonychia
Answer: B. It can be associated with iron deficiency anemia.
Koilonychia (shown) is characterized by spoon-shaped, concave nails. Causes of koilonychia include iron deficiency, diabetes mellitus, protein deficiency, systemic lupus erythematosus (SLE), exposure to petroleum-based solvents, trauma, and Raynaud disease.[1,4,11]
Left image from Wikimedia Commons | Nickyay. [CC by-SA 4.0 International.] Right image from Wikimedia Commons | Hojasmuertas. [CC by-SA 3.0.]
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Lindsay Nails and Terry Nail
Lindsay nails
Lindsay nails are shown in the image on the left.
The term Lindsay nails, also known as half-and-half nails, refers to a condition in which the proximal portion (40%-80%) of the nail bed is white and the distal portion is dark (red, pink, or brown).[12] The whiteness is related to edema and anemia.[4] Lindsay nails are seen in 20%-50% of patients with chronic kidney disease.[4,12,13]
Lindsay nails also have been reported in cirrhosis, Crohn disease, Behçet disease, pellagra citrullinemia, and Kawasaki disease, and they have been described in healthy persons.[14,15]
Terry nails
Terry nails are shown in the image on the right.
In the condition known as Terry nails, the proximal 80% of the nail bed is white, and the distal portion of the bed is a normal pink. Terry nails are caused by a reduced vascular supply to the nail bed.[15] They are indicative of hepatic disease, although they also can suggest diabetes mellitus, congestive heart failure, or hyperthyroidism; in addition, Terry nails can be related to aging.[15,16]
Images courtesy of Medscape.
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Lines on the Nails
Longitudinal brown lines (horizontal arrows) are shown in the image on the left. Beau lines (vertical arrow) are shown in the image on the right.
Longitudinal brown lines form as a result of increased melanin production by nail matrix melanocytes.[1] These lines are associated with Addison disease, nail matrix nevi, melanoma (check for periungual pigmentation), solar lentigines, certain medications, genetic predisposition, and trauma.[1,15]
Beau lines are transverse depressions in the nail plate resulting from temporary cessation of nail growth.[4,17] Causes include intermittent doses of immunosuppressive therapy or chemotherapy, nail injury, cold temperatures, and illness.[17] Severe zinc deficiency also has been proposed as a cause of Beau lines.[18]
Image courtesy of Gillian Weston, MD.
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Onychorrhexis
Onychorrhexis, or the presence of longitudinal striations or ridges on the nail plate, can simply be a sign of advanced age, but it also may be associated with conditions such as rheumatoid arthritis, peripheral vascular disease, lichen planus, and Darier disease (which includes broad white and red striations in the nails).[19]
Image from Wikimedia Commons | Splarka. [Public domain.]
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Splinter Hemorrhages
Splinter hemorrhages are caused by small areas of bleeding from the distal capillary loops in the nail bed and are most commonly associated with subacute bacterial endocarditis (classic finding) and local trauma.[4,20,21] These red or brown linear hemorrhages may also be associated with vasculitis,[20] microemboli,[20] trichinosis,[21] onychomycosis,[21] psoriasis,[21] SLE,[11] pityriasis rubra pilaris,[11] or renal failure.[11]
Image from Wikimedia Commons | Yannick Trottier. [CC by-SA 3.0.]
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Mees Lines
Any acute illness can produce transverse white lines, also known as Mees lines.[11] In addition, they may be caused by heavy metal toxicity (classically associated with arsenic poisoning), chemotherapy, carbon monoxide poisoning, Hodgkin disease, malaria, or leprosy.[22] The timing of the causative event or disease process may be determined from the location of the lines on the nails.[11,22,23]
Image courtesy of Gillian Weston, MD.
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Pitting of the Nails
Small punctate depressions of the nails, or "pitting," are caused by proximal nail matrix inflammation.[19] This inflammation most commonly is related to psoriasis (random appearance of pits), but it also is associated with alopecia areata (geometric, rippled grid), eczema, reactive arthritis, and lichen planus. Nail pitting also may occur without disease.
Images from DeMartinis NC, Cohen PR. Cureus. 2016;8(12):e922. [Open access.] PMID: 28090415, PMCID: PMC5222632. [CC by 3.0.]
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Pseudomonas aeruginosa Infection
The images show green discoloration of the right great toenail due to Pseudomonas aeruginosa infection. Note the green subungual pigmentation involving the nail and proximal nail fold on the superior view (left image) and on the underside of the nail plate on the frontal view (top right) (distal onycholysis allows easy visualization of the underside). The bottom right image shows the underside of the removed great toenail.
Image courtesy of Douglas A Albreski, DPM.
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Nail Unit Melanoma
An extremely rare condition, nail unit melanoma is responsible for about 1% of all melanomas in the White population. In contrast, it is the most common type of melanoma found in patients with darkly pigmented skin.
These cancers are often initially missed or diagnosed incorrectly, leading to a poorer prognosis. The patient presented here at first was treated with topical antifungals and then 3 months of terbinafine, for presumed onychomycosis, prior to a diagnosis of melanoma.[24,25]
Image courtesy of Douglas A Albreski, DPM.
15 Fingernail and Toenail Abnormalities
Mark P Brady, PA-C | August 21, 2023 | Contributor Information
Tuberous Sclerosis Complex
Tuberous sclerosis complex (shown) is a genetic disorder that causes benign tumors to grow in many different organs.[26] Ungual or periungual fibromas may appear in adolescents or adults with the condition. Fibromas may cause distortion of the nail or nail bed and can occur as an isolated sign of tuberous sclerosis. When these fibromas involve the toes, they may bleed and cause discomfort.
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Contributor Information
Author
Mark P Brady, PA-C
Adjunct Faculty and Preceptor
Physician Assistant Program
University of New England;
Physician Assistant
Department of Emergency Medicine
Cambridge Hospital, Cambridge Health Alliance
Cambridge, MA
Disclosure: Mark P Brady, PA-C, has disclosed no relevant financial
relationships.
Reviewer
Brett Sloan, MD, FAAD
Professor of Dermatology
Dermatology Residency Program Director
University of Connecticut School of Medicine;
Editor-in-Chief
Journal of the American Academy of Dermatology Case Reports
Farmington, CT
Disclosure: Brett Sloan, MD, FAAD, has disclosed the following
relevant financial relationships: Serve(d) as a director, officer,
partner, employee, advisor, consultant, or trustee for: Journal of
the American Academy of Dermatology
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References
Williams ME. Examining the fingernails when evaluating presenting symptoms in elderly patients. Medscape Family Medicine. November 23, 2009. Available at: https://www.medscape.com/viewarticle/712251. Accessed August 15, 2023.
Singh G. Nail changes and disorders in elderly. In: Sacchidanand S, Savitha AS, eds. Nail and Its Disorders. New Delhi, India: Jaypee Brothers Medical Publishers; 2013: chapter 6.
Williams ME. The hands and wrists. Geriatric Physical Diagnosis: A Guide to Observation and Assessment. Jefferson, NC: McFarland & Company, Inc, Publishers; 2008: chapter 5.
Khanna D, Singal A, Kalra OP. Comparison of cutaneous manifestations in chronic kidney disease with or without dialysis. Postgrad Med J. 2010;86:641-7.
Oanta A, Iliescu V, Tarean S. Half and half nails in a healthy person. Acta Dermatovenerol Croat. 2017;25(4):303-4.
Holzberg M, Walker HK. Terry's nails: revised definition and new correlations. Lancet. 1984 Apr 21;1(8382):896-9. PMID: 6143196
Lipner SR, Scher RK. Evaluation of nail lines: color and shape hold clues. Cleve Clin J Med. 2016 May;83(5):385-91. PMID: 27168515
Seshadri D, De D. Nails in nutritional deficiencies. Indian J Dermatol Venereol Leprol. 2012 May-Jun;78(3):237-41. PMID: 22565422
Hay RJ, Baran R. Fungal onychomycosis and other infections involving the nail apparatus. In: Baran R, de Berker DAR, Holzberg M, Thomas L, eds. Baran and Dawber's Diseases of the Nails and Their Management. Oxford, UK: John Wiley & Sons; 2012: chapter 5.
Schwartz RA, Jozwiak S, Pedersen R. Genetics of tuberous sclerosis. Medscape Drugs & Diseases from WebMD. Updated: September 2, 2021. Available at: https://emedicine.medscape.com/article/951002-overview. Accessed August 15, 2023.
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