1. NAILS

2. Anatomy
Nail plate: is the hard and translucent portion, composed of keratin
Its free edge is the part that
extends past the finger
2. Lunula : is the crescent
shaped whitish area of the nail bed
3. Eponychium or cuticle, is the fold of skin at the proximal end of the nail

3. 4. Nail fold : a fold of hard skin overlapping the base and sides of the nail
5. Nail matrix : situated directly below the cuticle.  New cells form here to produce the nail plate.  It also contains blood vessels and nerves. If the matrix is
damaged the nail
will grow deformed
6. Nail bed : It is
continuation of the
matrix and the part
that the nail plate
rests on

4. 7. Hyponychium:
is the attach-
ment between
the skin of the
finger or toe
and the distal
end of the nail

5. Nail growth and factors affecting it
The nail can take between months to grow from the matrix to the free edge
In children the growth is rapid 6 – 8 weeks
In adults nails grow approximately by 1 mm a week
Nail growth is quicker:
·  During pregnancy
·  In the summer than in the winter
· On the hands than the feet
If the matrix is damaged by trauma, the nail will grow back deformed

6. Nail growth is inversely proportional to age
With advancing years the nail plate becomes paler and opaque and white nails similar to those seen in cirrhosis, uraemia and hypoalbuminaemia may be seen in normal old persons
Longitudinal ridging is present to some degree in most people after 50 years of age

7. I-Nail disorders
1.Congenital
2.Traumatic
3.Infectious
4.Neoplastic

8. 1.Congenital
Anonychia
Some or all the fingernails and toenails are absent without significant bone anomalies
It is a rare condition
and may have an
autosomal dominant
inheritance pattern

9. Nail patella syndrome
A rare autosomal dominant syndrome
There is a tetrad of fingernail dysplasia with triangular lunula, absent or hypoplastic patellae, posterior
iliac horns,
deformation
of the radial
heads

10. Pachyonychia congenita
A rare autosomal dominant disease
There is hypertrophy of the nails associated in some cases with nail bed and hyponychia hyperkeratosis
May be associated with palmoplanter hyperkeratosis,
warty skin lesions
on the limbs,
hyperhidrosis and
lustreless and
kinky scalp hair

11. 2.Traumatic Acute trauma It is classified with respect to
severity, ranging
from a small
hematoma to
digit amputation

12. Chronic repetitive trauma
Nail biting
It is found in 60% of children, 45% of adolescents and 10% of adults
The majority of moderate nail biters have no associated psychiatric disorder
Patients are susceptible to bacterial and viral infections producing whitlows. It may also result in the transportation of bacteria that are buried under the surface of the nail, or pinworms from anus region to mouth
Regarding social effects the aesthetic aspect of the nail may affect employability, self-esteem, and interaction with other people

13. The nails are typically short, with up to 50% of thenail bed exposed.
The free edge may
be even or ragged.
Surface change may
include splitting of the
nail into layers or a
sand-papered effect,
and the nail may acquire a
brown longitudinal streak

14. Cure relies largely on the motivation of the patient
Local antiseptics and antimicrobial ointments may help settle the infection secondary to nail-unit damage
Antidepressants and behavioural therapy have been used with some success in limited studies

15. Hangnail
Trim the skin of the hangnail with a pair of clean scissors.
These are due to hard
pieces of epidermis breaking
away from the lateral nail
folds
Although often due to nail
biting, they may result from
many other minor injuries
The splits may be painful when they penetrate to the underlying dermis
They should be removed with sharp, pointed scissors

16. Trauma by footwear
Due to repetitive trauma by
footwear,the great toenail
becomes thickened, yellow
and twisted (onycho-
gryphosis). It is most
commonly seen in
the elderly

17. Treatment is either :
- Radical by surgical removal of the nail and matrix and is recommended in young persons with good circulation
- Palliative treatment requires regular paring and trimming of the affected nails, usually by a chiropodist

18. Ingrowing toenail
The lateral nail fold of the
great toe is penetrated
by the edge of the nail
plate, resulting in pain,
sepsis and, later, the
formation of
granulation tissue

19. The main cause for the deformity is compression of the toe from the side due to ill-fitting footwear
In infancy, ingrowing toenail most commonly occurs before shoes are worn, associated with crawling, or wearing undersized jumpsuits
Treatment is by:
-Avoiding tight-fitting or high-heeled shoes
- oral antibiotics or topical antibiotic ointments combined with local anaesthetic agents help to heal the toe faster and also provide pain relief
- Surgical removal of the ingrown toenail may be required if the condition worsens

20. 3-Nail infections Paronychia
It is a soft tissue infection around a fingernail
It results from a breakdown of the protective barrier between the nail and the nail fold leading to entry of bacteria or fungi into the area
It is the most common hand infection

21. Etiology Acute paronychia
Usually results from a minor(e.g. nail biting) trauma that breaks down the physical barrier between the nail bed and the nail allowing the infiltration of infectious organisms
S. aureus is the most common infecting organism. Organisms, such as Streptococcus and Pseudomonas species, gram-negative bacteria, and anaerobic bacteria are other causative organisms

22. Chronic paronychia
It is primarily caused by a mixture of C.albicans and bacteria
It can also be a complication of eczema
Most often it occurs in persons whose hands are repeatedly exposed to moist environments or in those who have prolonged and repeated contact with irritants such as mild acids, mild alkalis, or other chemicals. People who are most susceptible include housekeepers, dishwashers, and swimmers

23. Clinically Acute paronychia The presenting complaints
are pain, tenderness, and
swelling in one of the lateral
folds of the nail
The affected area often
appears erythematous
and swollen
In more advanced cases,
pus may collect under the
skin of the lateral fold

24. If untreated, the infection can
extend into the eponychium,
both lateral folds and in severe
cases, the infection may track
proximally under the skin of the
finger and volarly to produce a
felon (whitlow) which is an
abscess involving the
bulbous distal end of a finger

25. Chronic paronychia
Patients complain of symptoms lasting 6 weeks or longer
The nail folds become swollen, erythematous, and tender without fluctuance
Eventually, the nail plates become thickened and discolored, with pronounced transverse ridges
The cuticles and nail
folds may separate
from the nail plate,
forming a space for
the invasion of various
microorganisms

26. Treatment Acute paronychia
Oral antibiotics with gram-positive coverage against S aureus, such as amoxicillin and clavulanic acid (Augmentin) or clindamycin (Dalacine C), are usually administered concomitantly with warm water soaks 3-4 times/day
Dalacine C and Augmentin also have anaerobic activity; therefore, they are useful in treating patients with paronychia due to oral anaerobes contracted through nail biting

27. If the paronychia does not resolve or if it progresses to an abscess, it should be drained promptly

28. Chronic paronychia
The avoidance of moist environments or skin irritants is essential for recovery
Because of the 'mixed' etiology of the inflammation, many clinicians use antibiotic-anticandida-steroid creams combinations. Oral ketoconazole or fluconazole may be added in more severe cases
Patients with diabetes and those who are immunocompromised need more aggressive treatment because the response to therapy is slower in these patients than in others

29. Cryosurgery, using liquid nitrogen spray to the nail folds, or surgical removal of the proximal nail fold and adjacent part of the lateral nail folds, may cure recalcitrant cases

30. Pseudomonas infection
It is always a complication of onycholysis or chronic paronychia
The nail plate has a characteristic bluish-black or green color due to accumulation of the pigment pyocyanin below the nail which may remain after
the organism has been
removed
Treatment is as described
for paronychia
Gentamicin or sulphacetamide eye drops can be used to eradicate the colonization in resistant cases

31. 4-Tumors
Warts
Fibrokeratoma:They
arise in the periunguium
and have a hyper-
keratotic tip and narrow base
Subungual exostosis: It is a
benign bony outgrowth
of the distal part of the toe

32. Glomus tumour:
There is pain, which may be spontaneous or evoked by mild trauma or temperature change. Nail-plate changes depend on the location of the tumour. Matrix tumours cause splitting and distortion of the nail plate. Nail bed lesions are most likely to appear as bluish or red foci of 1-5mm diameter beneath the nail

33. Squamous cell carcinoma: There are hype-rkeratotic, warty changes, erosions and fissuring, macerated cuticle,
periungual swelling, erythema
Melanocytic nevi: Present as
longitudinal melanonychia

34. Malignant melanoma:There are many features that should suggest the possibility of malignant melanoma:
The presence of brown-black
periungual pigmentation
The pigmentation develops in
a single digit in adult life

35. The pigmentation is evolving to become darker and broader and has blurred edges
Longitudinal melanonychia(75% of cases)

36. Dermatoses affecting the nails
1-Psoriasis
Psoriasis is the most common
disorder affecting fingernails
(50% of psoriatics)
Pitting:Punctate surface depressions
Onycholysis:Separation of
the nail from the nail bed
either proximally or distally

37. Subungual hyperkeratosis:
most marked distally and
extends proximally
Splinter hemorrhage:may be
due to the increased capillary
prominence and
in nail-bed dermis

38. 2-Darier's disease There are white and red longitudinal lines and
distal notching

39. 3-Lichen planus
Nail involvement occurs in 10% of individuals with disseminated LP
Nail apparatus involvement may be the only manifestation
One, several, or all 20 nails may be involved ("twenty-nail syndrome," where there is loss of all 20 nails without any other evidence of lichen planus elsewhere on the body)

40. There is thinning of the nail plate and longitudinal ridging
Typically, the area of the
lunula is more elevated
than the more distal
portion

41. 4-Alopecia areata The nail plate is rough with a "hammered brass"
appearance

42. 5-Eczema Severe pompholyx around the nail folds may cause nail
dystrophy, resulting
in irregular ridges

43. Nail signs in systemic disease
I-Abnormalities of shape
1-Clubbing
It is the bulbous uniform swelling of the soft tissue of the terminal
phalanx of a digit with
subsequent loss of the
normal angle between
the nail and the nail bed
It is due to vasodilation of the digit blood vessels, the cause of which is unknown

44. 1-Primary (idiopathic)clubbing e.g. familial clubbing
Causes :
1-Primary (idiopathic)clubbing e.g. familial clubbing
2-Secondary clubbing include the following:
Pulmonary disease e.g. Lung cancer, cystic fibrosis
Cardiac disease e.g. Cyanotic congenital heart disease
GIT disease e.g. inflammatory bowel disease
Skin disease e.g. Pachydermoperiostosis
Malignancies e.g. Thyroid cancer, Hodgkin disease, leukemia
Miscellaneous conditions e.g. Acromegaly, pregnancy, and hypoxemia possibly related to long-term smoking of cannabis

45. 2-Koilonychia Nails become concave (spoon-shaped)
It is common in infancy as a benign feature of the great toenail
The most common
systemic association
is with iron deficiency

46. II-Changes in nail surface
Beau's lines
They are deep grooved lines
that run from side to side on
the fingernail due to a tempo-
rary cessation of cell division
in the nail matrix
This may be caused by an
infection or trauma in the
nail matrix
Beau's lines
Any severe systemic illness that disrupts nail growth, Raynaud's disease, pemphigus, trauma
Beau's lines
Any severe systemic illness that disrupts nail growth, Raynaud's disease, pemphigus, trauma
Beau's lines
Any severe systemic illness that disrupts nail growth, Raynaud's disease, pemphigus, trauma

47. Systemic reasons include: coronary occlusion, hypocalcaemia, diabetes, certain drugs - including beta blockers

48. Muehrcke's lines:
They are superficial (not grooved as beau’s line) white lines that extend all the way across the nail and lie parallel to the lunula
The lines are actually in the
vascular nail bed
underneath the nail plate,
and so they do not move
with nail growth and
disappear when pressure
is placed over the nail

49. The appearance of Meuhrcke's lines is nonspecific, but they are often associated with decreased protein synthesis, which may occur during periods of metabolic stress (e.g., after chemotherapy) and in hypoalbuminemic states such as the nephrotic syndrome

50. 'True' Leukonychia
It is the most common form of leukonychia, small white spots affecting one or two nails
Picking and biting of the nails are a prominent cause in young children
and nail biters
In most cases, they
disappear after around
eight months, which is
the amount of time
necessary for nails to
regrow completely

51. III-Changes in nail color
Terry’s nails
The nails are white proximally and normal distally
It occurs in cirrhosis,
congestive heart
failure and adult-
onset diabetes

52. Yellow nail syndrome
The nails are yellow due to
thickening, sometimes with
a tinge of green
The lunula is obscured and
there is increased transverse
and longitudinal curvature
and loss of cuticle
It is usually accompanied by
lymphoedema and pleural
effusions

53. Color changes due to drugs
Chloroquine may produce blue-
black pigmentation of the nail
Arsenic may produce
longitudinal bands of pigment
or transverse white stripes (Mees' stripes) across the nail

54. Nail cosmetics
Professional taking care of the fingernails is known as a manicure
Professional taking care of the toenails is known as a pedicure

55. Nail polish
In 1930, Charles Revson developed the first pigmented, opaque nail polish, which launched Revlon
Nail polish basically consists of pigments suspended in a volatile solvent to which film formers have been added. The ingredients are as follows:

56. 1-Cellulose film formers, such as nitrocellulose
1-Cellulose film formers, such as nitrocellulose. These give gloss, body and gel structure
2-Resins, such as toluene sulphonamide formaldehyde resin, to improve the gloss and adhesion of the film
Plasticizers, such as dibutylphthalate, added to give the film pliability, to minimize shrinkage, and soften and plasticize the cellulose
4-Suspending agents, such as bentonite, for non-settling and flow. They keep pigments in suspension on shaking

57. 5-Solvents (such as butyl) and diluents (such as toluene), which keep other ingredients in a liquid state and control the application and drying time
6-Color substances. These are either inorganic (iron oxides) or a variety of certified organic colors (D and C yellow, A1 lakes). In principle, they require to be insoluble in a nail lacquer system

58. Problems of nail polish
1-Contact dermatitis
Frequently appears on any part of the body accessible to the nails, with no signs in or around the nail
The commonest areas
involved are the eyelids,
the lower half of the face,
the sides of the neck and
the upper chest
Formaldehyde resin is
the most common cause

59. 2-Nail plate discoloration:
Nail-plate staining from the use of polish is most commonly yellow-orange in color
3-Nail polish removers:
These are composed of various solvents such as acetone which occasionally cause trouble by excessive drying of the nail plate and may be responsible for some inflammation of nail folds