Disorders of the nails

Professor Danka Švecová MD, PhD

Dept.of Dermatovenerology
Faculty of Medicine, Comenius University
 Disorders of the nails
Nail complex – a structural and functional unit;
consists of→ the plate, bed, matrix, proximal and lateral and distal
grooves, proximal and lateral folds, hyponychium

Healthy nail unit – important function → protection of the distal

phalanges, fingertip and surrounding soft tissue from external injury;
precise delicate movement of the distal digits
 Disorders of the nail plate
Onycholysis
Spontaneous separation at distal free margin; progressing to the
proximal edge; less often separation of nail plate begins at the
proximal nail and extends to its free edge (psoriasis of the nails
- onychomadesis)

Exogenous causes → repetitive minor mechanical trauma or

maceration (water, sugar onycholysis in confectioners) allergic
reaction triggered by various nail cosmetics
 Disorders of the nail plate
Onycholysis
Endogenous causes → iron deficiency, anemia, diabetes mellitus,
hyperthyroidism, hypothyroidism, pregnancy, scleroderma,
pemphigus vulgaris

The most common skin diseases associated with onycholysis →

psoriasis, lichen planus, contact dermatitis, atopic
dermatitis
 Disorders of the nail plate
Onychorhexis
„Brittle nails“- brittleness with breakage of nails may result from
dryness of the nails

Causes → excessive strong soap, water exposure, nail polish

remover, hypothyroidism, after oral retinoid therapy; vitamin B
deficiency, iron deficiency, malnutrition; 20% of population
 Disorders of the nail plate
Onychogryhosis
„claw or talon nails“
Causes → trauma, peripheral vascular disorder, neglection of
trimming the nails for a very long period

Predisposing factors → chronic venous insufficiency, anatomic

anomalies (halux valgus), association with some disorder of
keratinization; long term pressure exerted on the nails from
shoes
 Disorders of the nail plate
Onychogryhosis

Thickened nail plate → brownish-grey with rough surface, rounded

along its longitudinal axis resembling a claw, the nail becomes
distorted by growing away from its bed; it is impossible to trim the
nail;

The toes nails of elderly patients are affected, fingernails less

 Disorders of the nails
Koilonychia
Thin and concave nails with everted edges
„spoon-like shape“; often combine with onychorrhexis
several or even all nails are affected
Causes → nutritional deficiencies → iron;
in Raynaud disease, peripheral vascular diseases, repetitive
mechanical or chemical damages, familial forms
 Disorders of the nails
Platonychia
The nails are flat and broad;

Causes → trauma, chronic nail bites, thyroid disease,

vitamin deficiencies; transitory stage between a normal nail and
koilonychia
 Disorders of the nails
Onychodystrophy

Damage incurred to the nail matrix → apparent as the nail grows distally
 Disorders of the nails
Onychodystrophy
Beau´s lines → transverse furrows; begin in the matrix; progress
distally as the nail grows
one or more convex transverse lines run across the nail
bilateral or unilateral
Causes → acute febrile illness, drug reactions, paronychia, psoriasis,
erythroderma;
minor repetitive trauma to the nail fold and cuticule →horizontally
ridged nails (chronic manipulation of cuticule, recurrent paronychial
infections
 Disorders of the nail plate
Median canal dystrophy
Longitudinal splitting or canal formation in the midline of the nail;
the split may resemble a fir tree
occurs at the cuticle and precedes outward as the nail grows
usually the thumbnails are involved;

Causes → idiopathic, may bee inherited; repetitive trauma, it

persists for years
 Changes of the nail color
Leukonychia
„white nails“→ congenital or acquired
Leukonychia punctata - most common form, otherwise normal
nails; may follow a current episode of trauma
Leukonychia striata – may be hereditary, trauma or systemic
origin
Partial leukonychia – associated with tuberculosis, nephritis,
Hodgkin´s disease, metastatic carcinoma, leprosy, or idiopathic
 Changes of the nail color
Leukonychia
Leukonychia totalis
associated with typhoid fever, leprosy, cirrhosis
majority of cases → idiopathic
whitening appears spontaneously or due to minor trauma;
white color is due to incomplete keratinisation, and subsequent
retention of nuclear debris in the nail plate
 Changes of the nail color
Leukonychia
Mees lines → transverse lines of the same color as lunula;

cause → arsenic poisoning, thallium poisoning, or sudden nail

matrix damage
 Changes of the nail color
Leukonychia
Longitudinal white strakes → in Darier´s disease

DifDg – whitening of other origin: fungal infection, pallor of the nail

bed in hypalbuminemia
 Changes of the nail color
Half-and-half nails
Half-and-half nails → associated with renal diseases

The proximal nail bed is white and the distal half is red-brown
 Changes of the nail color
Yellow nail syndrome
Marked thickening and yellow to yellowish green discoloration
of the nails
Nails are over-curved both transversely and longitudinally
grow very slowly, often onycholysis
In systemic disease→ compromised respiration and
lymphoedema
 Changes of the nail color
Terry nail
Terry nail → proximal end or the entire nail plate has white
appearance → result of changes in the nail bed
the distal nail is of normal pink colour
Systemic disorders → cirrhosis, hypalbuminaemia, chronic
congestive heart failure, in very elderly patients
 Paronychia disorders
Paronychia

Soft tissue infection around a fingernail

it results from a breakdown of the protective barrier between
the nail and nail fold →results in bacterial or fungal colonization
of the area;

Risk factors → diabetes mellitus, obesity, hyperhidrosis, immunologic

defects, drug-induced immunosuppression
 Paronychia disorders
Acute paronychia
history of minor trauma to the fingertip or by nail manipulation
painful, tenderness and swelling in one of the lateral folds of nail,
Staphylococcus aureus → causative agent
 Paronychia disorders
Chronic paronychia
six weeks or longer; inflammation, pain, swelling – episodically
after an exposure to water or moist environment,
tender nail folds without fluctuation, cuticles and nail folds may separate
from the nail plate, forming a space for the invasion of various
microorganisms; Candida albicans → causative agent most often
 Paronychia disorders
Chronic paronychia
most often on the hands in person repeatedly exposed to moist
environments,
prolonged and repeated contact with irritants → housekeepers,
dishwashers, bartenders, swimmers;
Skin disorders → psoriasis, mucocutaneous candidiasis,
drug toxicity e.g. retinoids
 Ingrown nail (Unguis incarnatus)
Ingrown nail results from an alteration in the proper fitting of the nail
plate in it´s usual nail groove

Sharp spicule of the nail lateral margin → drives into the dermis
of the nail groove →the nail acts as a foreign body
 Ingrown nail (Unguis incarnatus)
Nail as a foreign body → inflammatory response – erythema,
edema, focal tenderness, later crusting, purulence at the nail
fold and nail plate junction → protuberant granulation tissue
extends over the nail plate;
 Ingrown nail (Unguis incarnatus)
Generally it occurs of poorly fitted footwear

Prior trauma resulting in an irregularly shaped nail, painful, the

discomfort worsens with weight bearing and ambulation
Nail changes associated with systemic disorders
Impaired peripheral circulation
( e.g. Raynaud disease) thinning – flattening or koilonychia;
onycholysis; white color
in contrast →impaired circulation in older persons →
thickening of the nail plate with onycholysis;
Acute digital ischemia may cause „blue nails“
Lymphoedema →yellow nail syndrome no lunula
Nail changes associated with systemic disorders
Chronic pulmonary disease
→clubbing – bulbous, club-like deformation of the distal portion
of fingers and toes from connective-tissue proliferation; later,
the distal phalanx becomes enlarged → increase in size
→not specific →idiopathic, familial, or associated with billiary
cirrhosis, ulcerative colitis
Nail changes associated with systemic disorders
Gastrointestinal disease
malabsorption leading to malnutrition →
horizontal ridges or altering bands of discoloration, lunula may
be absent
Renal disease
half-and-half nails, about 30% of dialysis patients have no lunula