Presentation on theme: "Lianne Beck, MD Assistant Professor Emory Family Medicine."— Presentation transcript:
Lianne Beck, MD Assistant Professor Emory 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
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 malnutrition Repetitive 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
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
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
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
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
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, hyperhydrosis Uncommon 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)
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
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.
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.
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
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.
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
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 wider Preceding 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 % 25% nodal spread
25% of nail melanomas Misdiagnoses Pyogenic granuloma Chronic granulation tissue Paronychia
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
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, 08.pdf Williams M. Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients. Medscape. 11/23/2009.