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Lianne Beck, MD Assistant Professor Emory Family Medicine.

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Presentation on theme: "Lianne Beck, MD Assistant Professor Emory Family Medicine."— Presentation transcript:

1 Lianne Beck, MD Assistant Professor Emory Family Medicine


3  Fingernails grow 2 -3 mm a month or 0.1 – 0.15 mm a day  Toenails grow 1 mm a month


5  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.

6  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

7 Onychorrhexis

8  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.

9  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 malnutrition  Repetitive trauma

10  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

11 Clubbing

12  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


14 Pitting

15  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.

16 Oil Spot Sign or Salmon Patch

17 Koilonychia

18  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

19 Onycholysis

20  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

21 Onycholysis

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


24  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, hyperhydrosis  Uncommon in children

25  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

26  The nail becomes thin, rudimentary and smaller size congenital or acquired.  Causes:  Lichen planus  Epidermolysis bullosa  Darier‘s disease  Vascular disturbances  Leprosy

27  Categories  Derm conditions: Psoriasis oil spot  Systemic drugs or ingestants: AZT, Minocin, Chemotherapy drugs  Systemic Disease: Mees Lines (Leukonychia)  Local agents: Cosmetics, physical agents

28  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.

29  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.





34  Originates in matrix and involves nail plate  Causes  Trauma  Systemic disease  Drugs  Heredity  Sporadic  Can be total, subtotal or partial (punctate or transverse)

35 Mee's lines

36  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


38 Muehrcke's Lines

39  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.

40 Terry’s Nails

41  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

42 Half and Half Nails

43  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.

44 Splinter Hemorrhages

45  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


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

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

49  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)

50  Diabetes mellitus  Amyloidosis  Median/ulnar nerve injury  Thermal injury  Jaundice

51  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.

52  Causes:  Topical preparations, including chlorophyll derivations, methyl green, and silver nitrate (among others)  Chronic Pseudomonas spp infection  Trauma

53 Melanonychia

54  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

55  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

56  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

57  Non-melanocytic tumors (Bowen’s Disease, Verrucae, Basal cell carcinoma, Subungual keratosis, Myxoid cyst)  Melanocyte hyperplasia  Nail matrix nevus  Nail matrix melanoma

58 Subungual Melanoma

59  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

60  Develops in a single digit in adult life especially in 6th decade or later  Develops abruptly in previously normal nail  Becomes suddenly darker or wider  Preceding history of digital trauma

61  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

62  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



65  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

66  Most patients present with late disease  5 year survival %  25% nodal spread

67  25% of nail melanomas  Misdiagnoses  Pyogenic granuloma  Chronic granulation tissue  Paronychia


69 Subungual Hematoma

70  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

71 Mucous or Myxoid Cyst

72  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

73 Pyogenic Granuloma

74  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

75  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.


77  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.


79  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.


81  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.


83  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).





88  Fawcett L, Linford S. Nail Abnormalities: Clues to Systemic Disease. American Family Physician. March 15,  08.pdf  Williams M. Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients. Medscape. 11/23/2009.

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