Nail Disorders: Clues to Systemic Disease

1. Lianne Beck, MD Assistant Professor Emory Family Medicine Nail Disorders: Clues to Systemic Disease

2. Nail Anatomy

3. Nail Anatomy • Fingernails grow 2 -3 mm a month or 0.1 – 0.15 mm a day • Toenails grow 1 mm a month

4. Beau's lines

5. Nail Shape and Surface • 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. Thin Brittle Nails • 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. Onychorrhexis • 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. Central Nail Canal (Median Nail Dystrophy) • 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. Nail Beading • 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. Clubbing • 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. Pitting • 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. Koilonychia • 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. Onycholysis • 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 • Porphyriacutaneatarda • Amyloidosis, connective tissue disorders

21. Onycholysis

22. Nail hypertrophy • Causes • Onychomycosis • Chronic eczema • Peripheral vascular disease • Yellow nail syndrome • Psoriasis • Not cutting the nails, trauma

23. Onychomycosis

24. Onychomycosis • 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. Reasons for Relapse • 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. Nail atrophy • The nail becomes thin, rudimentary and smaller size congenital or acquired. • Causes: • Lichen planus • Epidermolysis bullosa • Darier‘s disease • Vascular disturbances • Leprosy

27. Pigmentation Abnormalities • 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. Diagnostic Pearls • 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. Abnormalities of the Lunula • 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.

31. Argyria

34. Leukonychia (White Nails) • 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. Mee's lines • 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

37. LeukonychiaStriae caused by trauma to the matrix from aggressive manicuring, involves only a few nails & does not extend across the entire nail plate.

38. Muehrcke's Lines

39. Muehrcke's Lines • 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. Terry's Nails • 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. 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.

44. Splinter Hemorrhages

45. Splinter Hemorrhages • 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. White Nails • Causes: • Anemia • Renal failure • Cirrhosis • Diabetes mellitus • Chemotherapy • Hereditary (rare).

48. Pink or Red Nails • Causes: • Polycythemia (dark) • Systemic lupus erythematosus • Carbon monoxide (cherry red) • Angioma • Malnutrition

49. Brown-Gray Nails • 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. Yellow Nails • Diabetes mellitus • Amyloidosis • Median/ulnar nerve injury • Thermal injury • Jaundice