diseases of the nail


Presentation Description

No description available.


Presentation Transcript




INTRODUCTION A nail is a horn -like structure at the end of a person's (or an animal's) finger or toe . The nail is generally regarded as a distinctively primate feature. Although it is not a feature confined exclusively to primates, the development of nails is extremely rare in other mammals

Parts of the Nail :

Parts of the Nail Matrix The only living part of the nail. It is situated behind and underneath the nail fold and produces the keratin which makes up the nail plate. If the matrix is damaged, growth of the nail plate is affected . Eponychium Dead skin that forms around the cuticle area. It can be lifted and trimmed during a professional manicure treatment. Tends to be more prominent on males . Paronychium The 'live' skin that folds around the cuticle area, giving protection to the matrixHyponychiumThe area of attachment between the nail plate and nail bed that lies underneath the free edge. Anatomical terms of location: proximal and distal, end of the nail . Nail plate The hard and translucent part of the nail composed of layers of keratinNail bed.Tissue underneath the nail plate, responsible for the pink colour of the nail. It also determines what shape the nail will grow. It is informally referred to as "the quick", especially the end nearest the fingertip .

PowerPoint Presentation:

Lunula -The visible part of the matrix, a whitish crescent shape around the base of the nail plate. Tends to only be visible in larger nails. Nail fold - A fold of hard skin overlapping the base and sides of a fingernail or toenail .The part of the nail that extends past the finger, beyond the nail plate. There should always be a free edge present to prevent infections. Ideally a free edge should be no longer than half of the 'pink' nail in length. Nail groove -Grooves that guide the direction of nail growth. They are located down the sides of the nail fold.

Growth :

Growth Nails grow at an average rate of 3 millimeters (1/8 inch) a month (as they are a form of hair ). Fingernails require 3 to 6 months to regrow completely, and toenails require 12 to 18 months. Actual growth rate is dependent upon age, gender, season, exercise level, diet, and hereditary factors. Nails grow faster in the summer than in any other season. [3] Contrary to popular belief, nails do not continue to grow after death; the skin dehydrates and tightens, making the nails (and hair) appear to grow. [4]

PowerPoint Presentation:

Careful examination of the fingernails and toenails can provide clues to underlying systemic diseases . Clubbing , which is one example of a nail manifestation of systemic disease, was first described by Hippocrates in the fifth century B.C. Since that time, many more nail abnormalities have been found to be clues to underlying systemic disorders.

Descriptive terms:

Descriptive terms Onychia is an inflammation of the matrix (surrounding tissue) of the nail with formation of pus and shedding of the nail. Onychia results from the introduction of microscopic pathogens through small wounds . Onychocryptosis , commonly known as "ingrown nails" ( unguis incarnatus ), can affect either the fingers or the toes. In this condition, the nail cuts into one or both sides of the nail bed, resulting in inflammation and possibly infection. The relative rarity of this condition in the fingers suggests that pressure from the ground or shoe against the toe is a prime factor.Mild onychocryptosis , particularly in the absence of infection, can be treated by trimming and rounding the nail. More advanced cases, which usually include infection, are treated by surgically excising the ingrowing portion of the nail down to its bony origin and thermally or chemically cauterizing the matrix, or 'root', to prevent recurrence. This surgery is called matrixectomy . The best results are achieved by cauterizing the matrix with phenol . Another, much less effective, treatment is excision of the matrix, sometimes called a 'cold steel procedure '. Onychodystrophy is a deformation of the nails that can result from cancer chemotherapy which includes bleomycin , hydroxyurea , or 5-fluorouracil. It can include discoloration of the nail, or dyschromia . Onychogryposis , also called "ram's-horn nail", is a thickening and increase in curvature of the nail. It is usually the result of injury to the matrix. It may be partially hereditary and can also occur as a result of long-term neglect. It is most commonly seen in the great toe but may be seen in other toes as well as the fingernails. An affected nail has many grooves and ridges, is brownish in color, and grows more quickly on one side than on the other. The thick curved nail is difficult to cut, and often remains untrimmed, exacerbating the problem.

PowerPoint Presentation:

Onychophosis is a growth of horny epithelium in the nail. Onychoptosis is the periodic shedding of one or more nails, in whole or part. This condition may follow certain diseases such as syphilis , or can result from fever , trauma , systemic upsets or adverse reaction to drugs. Paronychia is a bacterial or fungal infection where the nail fold. Koilonychia is when the nail curves upwards (becomes spoon-shaped) due to an iron deficiency . The normal process of change is: brittle nails, straight nails, spoon-shaped nails. Subungual hematoma occurs when trauma to the nail results in a collection of blood, or hematoma , under the nail. It may result from an acute injury or from repeated minor trauma such as running in undersized shoes. Acute subungual hematomas are quite painful, and are usually treated by releasing the blood by creating a small hole in the nail. Drilling and thermal cautery (melting) are common methods for creating the hole. Thermal cautery is not used on acrylic nails because they are flammable.

Onychia :




Subungual haematoma :

Subungual haematoma

Paronychia :


Candidal paronychia:

Candidal paronychia

Pincer nail deformity:

Pincer nail deformity

Shape or growth change:

Shape or growth change Shape or growth change Koilonychia Iron deficiency anemia, hemochromatosis , Raynaud’s disease, SLE, trauma, nail-patella syndrome Onycholysis Psoriasis, infection, hyperthyroidism, sarcoidosis , trauma, amyloidosis , connective tissue disorders Pitting Psoriasis, Reiter’s syndrome, incontinentia pigmenti , alopecia areata Beau’s lines Any severe systemic illness that disrupts nail growth, Raynaud’s disease, pemphigus , trauma Yellow nail Lymphedema , pleural effusion, immunodeficiency, bronchiectasis , sinusitis, rheumatoid arthritis, nephrotic syndrome, thyroiditis , tuberculosis, Raynaud’s disease

Clubbing :

Clubbing Clubbing of the nails  is a thickening of the soft tissue beneath the proximal nail plate that results in sponginess of the proximal plate and thickening in that area of the digit . The cause of clubbing is poorly understood; the condition may result from megakaryocytes and platelet clumps that have escaped filtration in the pulmonary bed and have entered the systemic circulation. Platelets then may release platelet-derived growth factor at the nail bed, causing periosteal changes. The angle between the finger proximal to the nail and the proximal nail plate is straightened, creating the “ Schamroth sign,” which is an obliteration of the normally diamond-shaped space formed when dorsal sides of the distal phalanges of corresponding right and left digits are opposed

Schamroth sign:

Schamroth sign


CAUSES Lung disease: Lung cancer , mainly large-cell (35% of all cases), not seen frequently in small cell lung cancer [6] Interstitial lung disease Tuberculosis Suppurative lung disease: lung abscess , empyema , bronchiectasis , cystic fibrosis Mesothelioma A·V fistula Heart disease: Any disease featuring chronic hypoxia Congenital cyanotic heart disease (most common cardiac cause) Subacute bacterial endocarditis Atrial myxoma (benign tumor) Gastrointestinal and hepatobiliary : Malabsorption Crohn's disease and ulcerative colitis Cirrhosis , especially in primary biliary cirrhosis Hepatopulmonary syndrome , a complication of cirrhosis Laxative abuse Polyposis Esophageal CA Others: Hyperthyroidism ( thyroid acropachy ) Familial and racial clubbing and " pseudoclubbing " (people of African descent often have what appears to be clubbing) Vascular anomalies of the affected arm such as an axillary artery aneurysm (in unilateral clubbing) Thymoma Thalassemia




KOILONYCHIA Koilonychia is a nail disease that can be a sign of hypochromic anemia , especially iron-deficiency anemia . Koilonychia literally means "spoon nails." It refers to abnormally thin nails (usually of the hand) which have lost their convexity, becoming flat or even concave in shape . In a sense, koilonychia is the opposite of nail clubbing .

Causes :

Causes normal nail variant in infants, but it usually corrects itself within the first few years of life. trauma constant occupational exposure of the hands to petroleum-based solvents, nail-patella syndrome .- autosomal -dominant condition that includes hypoplastic , easily dislocated patellas , renal and skeletal abnormalities, and glaucoma. Koilonychia has been associated with iron deficiency, with or without resultant anemia. Interestingly, it occasionally occurs in patients with hemochromatosis. 12 Patients with Raynaud’s disease or lupus erythematosus can have spooning, but it usually is not an isolated finding


PITTING Pitting of the nails shows as punctate depressions in the nail plate. Pitting usually is associated with psoriasis, affecting 10 to 50 percent of patients with that disorder.It is also found in allopecia areata . Pitting also may be caused by a variety of systemic diseases, including Reiter’s syndrome and other connective tissue disorders, sarcoidosis , pemphigus , alopecia areata , and incontinentia pigmenti . Because pitting is caused by defective layering of the superficial nail plate by the proximal nail matrix, any localized dermatitis (e.g., atopic or chemical dermatitis) that disrupts orderly growth in that area also can cause pitting.


ONYCHOLYSIS Onycholysis , which occurs when the nail plate is separated from the nail bed, results in white discoloration of the affected area. It can be caused by any local problem, such as periungual warts or onychomycosis , that separates the nail plate from the bed, although the most common reason for this separation is trauma. Onycholysis can accompany psoriasis when the distal portion of the nail matrix is affected If no clear local cause is discovered, a diagnosis of hyperthyroidism should be considered. In patients with hyperthyroidism, onycholysis is known as “Plummer’s nails.” Hyperthyroidism also can cause brown discoloration of the nail plate . Yellow nail syndrome - Yellow nail syndrome is characterized by yellow or green nails that lack a cuticle, grow slowly, and are loose or detached ( onycholysis ). May be associated with swelling of the hands and feet ( lymphoedema ), or a lung diseases e.g. chronic bronchitis .

Yellow nail syndrome:

Yellow nail syndrome

PowerPoint Presentation:

Transverse Linear Lesions


BEAUS LINES Transverse linear depressions in the nail plate have been called Beau’s lines since these lesions originally were described in 1846. Beau’s lines occur at the same spot of the nail plate in most or all of the person’s nails and may be caused by any disease severe enough to disrupt normal nail growth . Knowing that nails grow about 1 mm every six to 10 days, the timing of the disease process may be estimated by measuring the distance from the line to the nail bed. Causes may include trauma , coronary occlusion , hypocalcaemia , skin disease, and may be a sign of systemic disease. It may also be caused by an illness of the body, such as diabetes , psoriasis , certain drugs—including beta blockers , as well as other drugs used in chemotherapyn or even malnutrition .


MEES LINES Classically associated with arsenic poisoning, Mees ’ lines are transverse white bands that frequently affect multiple nails, although they also may occur singly. If arsenic poisoning is suspected, hair or tissue samples should be obtained for verification; however, Mees ’ lines also may be associated with multiple other conditions

Muehrcke’s lines:

Muehrcke’s lines Pairs of transverse white lines that extend all the way across the nail are called Muehrcke’s lines . The lines represent an abnormality of the vascular nail bed and disappear while the nail is depressed and blood is squeezed from the vessels beneath the nail . Because the lesion is in the nail bed, it does not move with nail growth. These characteristics distinguish Muehrcke’s lines from Mees ’ lines. Muehrcke’s lines occur in patients with hypoalbuminemic states (i.e., albumin level less than 2 g per dL [20 g per L]) and disappear when the protein level normalizes. They also may be present in patients with nephrotic syndrome, liver disease, and malnutrition. 9


Leukonychia Children and active adults commonly have one or more white lines or spots on one or more nails; this condition is known as leukonychia . These lines and spots are nonuniform , appear in different places on different nails, do not span the nail, and are of no significance. They are thought to result from random minor trauma to the proximal nail bed. Unlike leukonychia , Mees ’ and Muehrcke’s lines are always parallel to the edge of the lunula .

PowerPoint Presentation:

Longitudinal Linear Lesion


MELANONYCHIA Longitudinal pigmented bands are normal findings in the nails of dark-skinned persons, occurring in more than 77 percent of blacks older than 20 years .These findings present a diagnostic problem because they must be differentiated from subungual melanomas , which also occur in older age groups and constitute 50 percent of melanomas in dark-skinned populations. Nail symptoms in patients with increased likelihood should be considered melanoma until proved otherwise by biopsy

PowerPoint Presentation:

Longitudinal striations are accentuated ridges in the nail surface that can occur as a normal part of the aging process . If nails become thin and lusterless (i.e., sandpapered appearance), the condition may be referred to as trachyonychia ; when all of the nails are affected, the condition is called 20-nail dystrophy . In this situation, associated conditions, including alopecia areata , psoriasis, atopic dermatitis, and lichen planus , must be considered. 18 Trachyonychia also may be seen in patients with vitiligo. 19

PowerPoint Presentation:

Nail Bed and Vascular Change

Cyanosis :

Cyanosis A bluish discoloration visible at the nail bases in select patient with severe hypoxemia or hypoperfusion . As with clubbing, it is not at all sensitive for either of these conditions.

Splinter hemorrhages:

Splinter hemorrhages Splinter hemorrhages are longitudinal thin lines, red or brown in color, that occur beneath the nail plate. They are visible when capillaries within the epidermal ridges leak . While splinter hemorrhages may denote benign problems such as local trauma, psoriasis, or localized fungal infection, they are a classic finding in patients with endocarditis Splinter hemorrhages are thought to be a more specific indicator of endocarditis if they are present proximally rather than distally on the nail plate, and they are more common in subacute than acute infection However, splinter hemorrhages occur in only about 15 percent of patients with endocarditis and may be present in up to 20 percent of persons without endocarditis . The causes of splinter hemorrhage are so varied and common that their usefulness as an isolated sign of illness has been questioned, 7 except when they are accompanied by fever, Roth’s spots, Osler’s nodes, Janeway’s lesions or a murmur, any of which would greatly increase their significance.

PowerPoint Presentation:

Changes in the color of the lunula can be revealing . In patients with Wilson’s disease the area takes on a blue coloration, a phenomenon called azure lunula . Heart failure can turn the lunula red , tetracycline therapy can turn it yellow. Silver poisoning will turn the nail itself a blue-gray color . Excessive fluoride ingestion can turn nails brown or black.

Yellow nails in tetracycline therapy:

Yellow nails in tetracycline therapy

Terry’s nails:

Terry’s nails In patients with Terry’s nails, most of the nail plate turns white with the appearance of ground glass, and the lunula is obliterated. The condition may occur on only one finger, but more commonly all fingers are affected. This condition was described originally in relation to severe liver disease, usually cirrhosis, with 80 percent of these patients having Terry’s nails. The condition is thought to be caused by a decrease in vascularity and an increase in connective tissue in the nail bed. 24

HALF AND HALF NAILS (Lindsay's nails):

HALF AND HALF NAILS (Lindsay's nails) Similarly, in patients with chronic renal failure, increased melanin production may cause the distal part of the nail bed to turn brown . In patients with severe renal disease, the proximal portion of the nail bed can turn white, obliterating the lunula and giving a half-brown, half-white appearance, also called half-and-half nails

PowerPoint Presentation:

Nail changes in selected conditions

Nail changes in psoriasis:

Nail changes in psoriasis Oil drop or salmon patch/nail bed 2 : This lesion is a translucent, yellow-red discoloration in the nail bed resembling a drop of oil beneath the nail plate. This patch is the most diagnostic sign of nail psoriasis . Pitting/proximal nail matrix : Pitting is a result of the loss of parakeratotic cells from the surface of the nail plate . Beau lines/proximal nail matrix : These lines are transverse lines in the nails due to intermittent inflammation causing growth arrest lines . Leukonychia / midmatrix disease : Leukonychia is areas of white nail plate due to foci of parakeratosis within the body of the nail plate . Subungual hyperkeratosis/ hyponychium : Subungual hyperkeratosis affects the nail bed and the hyponychium . Excessive proliferation of the nail bed can lead to onycholysis . Onycholysis /nail bed and nail hyponychium : Onycholysis is a white area of the nail plate due to a functional separation of the nail plate from its underlying attachment to the nail bed. It usually starts distally and progresses proximally, causing a traumatic uplifting of the distal nail plate. Secondary microbial colonization may occur. Nail plate crumbling/nail bed or nail matrix : Nail plate weakening due to disease of the underlying structures causes this condition. Splinter hemorrhage/dilated tortuous capillaries in the dermal papillae: Splinter hemorrhages are longitudinal black lines due to minute foci of capillary hemorrhage between the nail bed and the nail plate. This is analogous to the Auspitz sign of cutaneous psoriasis, which is the pinpoint bleeding seen beneath the psoriatic plaques. Spotted lunula /distal matrix : This is an erythematous patch of the lunula . Psoriatic arthritis with nail changes/phalanx

Nail involvement in allopecia areata:

Nail involvement in allopecia areata Nail involvement is found in 6.8-49.4% of patients and most commonly is seen in patients with severe forms of alopecia areata . Pitting is the most common finding. Several other abnormalities have been reported ( eg , trachyonychia , Beau lines, onychorrhexis , onychomadesis , koilonychia , leukonychia , red lunulae ). Fingernails predominantly are affected.


O nychomycosis onychomycosis means fungal infection of the nail . [2] It is the most common disease of the nails and constitutes about a half of all nail abnormalities. [3]

PowerPoint Presentation:

There are four classic types of onychomycosis : [10] :305 Distal subungual onychomycosis The most common form of tinea unguium usually caused by Trichophyton rubrum , which invades the nail bed and the underside of the nail plate . White superficial onychomycosis Caused by fungal invasion of the superficial layers of the nail plate to form "white islands" on the plate. Accounts for only 10 percent of onychomycosis cases . Proximal subungual onychomycosis Fungal penetration of the newly formed nail plate through the proximal nail fold. It is the least common form of tinea unguium in healthy people but found more commonly when the patient is immunocompromised . Candidal onychomycosis Candida species invade fingernails usually occurring in persons who frequently immerse their hands in water. This normally requires the prior damage of the nail by infection or trauma.

Distal subungual onychomycosis. Subungual hyperkeratosis onycholysis and yellow streak. :

Distal subungual onychomycosis . Subungual hyperkeratosis onycholysis and yellow streak .

White superficial onychomycosis. :

White superficial onychomycosis .

Proximal subungual onychomycosis. Proximal leukonychia. :

Proximal subungual onychomycosis . Proximal leukonychia .

Candidal onychomycosis in a patient with chronic mucocutaneous candidiasis. Total onychomycosis and paronychia. :

Candidal onychomycosis in a patient with chronic mucocutaneous candidiasis . Total onychomycosis and paronychia .

Nail findings in Lichen planus:

Nail findings in Lichen planus In 10% of patients, ungual findings are present. Most commonly, nail plate thinning causes longitudinal grooving and ridging. Hyperpigmentation , subungual hyperkeratosis, onycholysis , and longitudinal melanonychia can result from lichen planus . Rarely , the matrix can be permanently destroyed with prominent pterygium formation. Lichen planus has been linked to childhood idiopathic nail atrophy and may overlap with twenty-nail dystrophy of childhood.

Nutritional deficiencies:

Nutritional deficiencies Vitamin A and calcium deficiencies - dry brittle nails. Vitamin B deficiency - horizontal and vertical ridges, that break easily. Vitamin B12 deficiency- dry, darkened nails with rounded and curved nail ends. Protein deficiency- white bands

PowerPoint Presentation:

Thank you

authorStream Live Help