NAILS

Nail Disorders and Abnormalities

Nail abnormalities are common. Appearances may be difficult to diagnose with certainty and care must be taken to ensure correct diagnosis and therefore treatment.

Some common nail disorders 

Ingrowing toenail: 

·               Common problem resulting from various causes, e.g. improperly trimmed nails, hyperhidrosis, and poorly fitting shoes.

·               Often presents with pain, but may progress to infection and difficulty with walking.

·               Treatment options include cutting nails square, hot water soaks, antibiotics for excision, and wedge excision or total excision of nail.

Beau's lines: 

·               Transverse ridges are usually transient and due to a temporary disturbance of nail growth, e.g. severe illness.

·               Caused by Pseudomonas infection.

Green nails: 

·               Caused by Pseudomonas infection.

Blue nails:

·               May occur as a side effect of anti-malarial drugs

Black nails: 

·               May be a feature of Peutz-Jegher's disease, vitaminB12 deficiency and post-irradiation.

·               Black streaks may indicate a junctional melanocytic naevus or malignant melanoma.

Leuconychia (white nail):

·               May be congenital or due to minor trauma, hypoalbuminaemia in chronic liver disease, renal failure, fungal infection or lymphoma.

Yellow nail syndrome: 

·               Slow growing, excessively curved and thickened yellow nails which are associated with peripheral lymph oedema and exudative pleural effusions.

Clubbing:

·               An increase in the soft tissue of the distal part of the fingers or toes. Common causes of finger clubbing include: Cyanotic congenital heart disease, infective endocarditis, Lung cancer, pulmonary fibrosis, cystic fibrosis, bronchiectasis, emphysema, lung abscess.

Koilonychia:

·               Dystrophy of the fingernails in which they are thinned and concave with raised edges (spoon shaped nails).

·               May be due to iron deficiency or trauma.

Nail-patellar syndrome:

·               Congenital nail disorder, autosomal dominant inheritance

·               The patellae and some of the nails are rudimentary or absent.

Longitudinal ridging:

·              Causes include alopecia areata, lichen planus, rheumatoid arthritis and peripheral vascular disease. 

Onycholysis

Longitudinal ridging:

·               Nail becomes detached from its bed at base and side, creating a space under nail that accumulates dirt. Air under nail may cause grey-white colour but can vary from yellow to brown.

·               In psoriasis can see yellowish-brown margin between margin between normal nail (pink) and detached parts (white).

·               Pseudomonas aeruginosa grows underneath nail, then green colour.
When nail bed separation begins in middle of nail then appearance resembles an 'oil spot' or 'salmon-patch'.  

Causes of onycholysis include:

·               Idiopathic or inherited

·               Systemic disease, e.g. thyrotoxicosis

·               Skin disease, e.g. psoriasis

·               Local causes, e.g. trauma or chemicals  

Onychogryphosis

Thickening of nail plate mainly seen on big toes of elderly associated with injury to foot, badly fitting shoes or poor blood supply. 

Central longitudinal grooves dystrophy:

·               Central grooves in centre of nail. Also cuticle is pushed back and inflamed.

·               Most commonly results from compulsive habit of patient picking at proximal nail fold thumb with index fingernail.

·               Disappears if patient stops habit

Splinter haemorrhages: 

Splinter haemorrhages are linear haemorrhages lying parallel to the long axis of finger or toe nails.

Causes include: 

·               Trauma

·               Infective endocarditis

·              Vasculitis, e.g. rheumatoid arthritis, systemic lupus erythematosus, polyarteritis nodosa

·               Haematological malignancy

·               Severe anaemia

Psoriasis

·              Virtually all patients with psoriasis have nail involvement at some time and occurs in 50% of cases at any given time.

·              Abnormalities include nail pits, transverse furrows, crumbling nail plate, roughened nails.

·               Nail pitting is associated with alopecia areata as well as with psoriasis.

·              Can sometimes see in nail bed 'oil spot', distal onycholysis, distal subungual hyperkeratosis, splinter haemorrhages and false nail following spontaneous separation of nail plate.

Lichen planus

·               Nails involved in approximately 10% of cases of disseminated lichen planus. However, may be only presentation of disease.

·              With matrix causes thinning, brittleness, crumbling of the nail with accentuated surface longitudinal ridging and colour change to black or white.

·               Typically the lunula is raised more than the distal part of the nail.

·               Severe chronic inflammation causes either partial or complete loss of nail plate and formation of pterygium (see picture below) with partial loss of central nail plate seen as distal notch or completely split nail. Involvement of nail bed causes onycholysis, distal subungual hyperkeratosis, formation of bulla or permanent anonychia.

·               Lichen planus can affect any number of nails.

·               Treatment: injection of steroid into proximal nail fold.

Nail Tumours

Squamous cell carcinoma

·           Usually caused by infection with human papillomavirus types 16 and 18.

·           Skin-coloured or hyperpigmented lesions appearing as keratotic or hyperkeratotic or warty papules and plaques found on the proximal and lateral nail folds and hyponychium.

·           Squamous cell carcinoma in situ (SCCIS) can extend into the nail bed producing onycholysis.

·           Invasive SCC arising within SCCIS can cause pain if invades bone.

·           Occurs much more commonly on fingers, usually thumb and index finger usually as solitary lesion.

·           Can involve multiple fingers in immunocompromised patients.

·           Treat with CO2 laser ablation, Mohs' surgery or amputation of digit if necessary.

Nail matrix nevomelanocytic nevus 

·               Presents as a longitudinal brown strip in the nail bed.

Acrolentiginous melanoma 

·               Mostly seen in thumb and big toe with brown-black pigmentation of nail extending to proximal and lateral nail folds and even beyond the nail (Hutchinson's sign), usually without other symptoms.

·               Mean age of patients is 55-60 years.

·               Cause of 2-3% of melanomas in white patients and 1 in 5 or 6 black patients.

·               Diagnosis is by biopsy. 5 years survival is 35-50% 

Fungal Nail Infections - Onychomycosis

Synonyms: Onychomycosis, OM, tinea unguium.

Various fungi may infect the nails of the hands or feet, and can affect any part of the nail from the nail bed, to the nail matrix and plate. Its most common consequence is a poor cosmetic appearance of the affected nail(s), but the condition may also have functional effects and cause discomfort, pain, frank disfigurement, limitation of mobility or inability to carry out certain jobs. The condition may also have adverse psychosocial and emotional effects (for instance, a reluctance to bare the feet in public, to use public baths, to take part in sport where there are communal changing facilities). There are several patterns of presentation and infecting organisms.

Epidemiology 

This is one of the commonest dermatological conditions in the UK. Questionnaire surveys suggest a background prevalence of 2.71% of the population. Mycologically-controlled surveys in Finland and The United States indicate a prevalence of 7–10%. The toenails are affected in about 80% of cases of onychomycosis. The incidence of new cases of onychomycosis appears to be rising due to the increasing prevalence of diabetes in the population, more frequent incidence of immunosuppression and an ageing population.

Risk factors

·               Age – adults are ~30 times more likely than children to suffer the condition (affects 2.6% of children younger than 18 years, but as many as 90% of people older than 70 years).

·               Immunosuppression – illness or medications that suppress immune responses greatly increase the likelihood of suffering onychomycosis.

·               Diabetes mellitus – it can affect up to 30% of diabetic patients3

·               Cutaneous fungal infection – around 30% will also have onychomycosis1

·               Warm, humid climate

·               Participation in athletic/sporting activities

·               Prior trauma to nail

·               Regular communal bathing

·               Occlusive footwear, e.g. rubberised plimsolls for maritime recreation

·               Peripheral vascular disease

Infecting organisms 

Dermatophytes:
Trichophyton rubrum or T. mentagrophytes causes over 90% of cases4, with T. rubrum being responsible for about 70% of the total.1 Other organisms in this group include Epidermophyton sp. and Microsporum sp. 

Yeasts:
Cause ~8% of total infections; particularly Candida albicans in the UK and Malassezia fur fur in tropical climes. 

Non-dermatophyte moulds:

Cause about 2% of total infections, e.g. Scopulariopsis brevicaulis. 

Distal and lateral subungual onychomycosis (DLSO)

·               Is the commonest form and is virtually always caused by dermatophytes.

·               Infection starts under front of nail or nail fold and extends under the nail to involve the whole structure. Can either affect a healthy nail or one already diseased, e.g. by psoriasis.

·               Approximately 80% of cases occur on the feet, especially on big toes often affecting both toe and fingernails.

·               Initially presents as white patch on the under surface of the nail and nail bed but becomes discoloured to brown or black.

·               Progression can incur within weeks or more slowly over months or years with the nail becoming opaque, thickened and cracked, friable and raised from the nail bed. 

Superficial white onychomycosis(SWO) 

·               Usually caused by dermatophyte invading surface of dorsal nail plate presenting as white chalky plaque on proximal nail plate almost exclusively on the toenails.

·               Nail plate may become eroded and even lost.

Proximal subungual onychomycosis

·               Almost always associated with immunocompromised patients presenting as a white spot beneath the proximal nail fold which eventually fills the lunula occurring most commonly on toenails.

·               Eventually can involve whole of the under surface of the nail plate.

Candida onychomycosis

Occurs in 3 different types:

·               Candida paronychia: initially appears as oedema, erythema and pain of the nail fold from which pus can be expressed at times. Also nail plate becomes dystrophic with patches of opacification or discolouration (white, yellow, green or black) with transverse furrows. Usually, pressure on the nail causes pain. Most cases are on fingernails usually middle finger.

·               Subungual abscess with DLSO occurring in the setting of onycholysis (see above).

·               Total nail dystrophy: affects all or large proportion of nails associated with chronic mucocutaneous candidiasis. Entire fingernail may become thickened and dystrophic.

       Diagnosis of above is by direct microscopy.

·               Without treatment, condition often spreads to multiple toenails and can form a portal for recurrent bacterial infections.

·               Common in diabetics and can contribute to foot problems.

·              Treatment is with systemic antifungal agents: terbinafine, itroaconazole, fluconazole.

·              Because of slow growth of nails, they do not appear normal even after effective treatment and treatment can be stopped when culture and potassium hydroxide preparations are negative.

·               Patients should practise long term prophylaxis with benzoyl peroxide soap for washing feet, antifungal cream daily, antifungal sprays or powder for shoes.

Paronychia 

Paronychia is inflammation of the tissue around the finger nail, with pus accumulating between the cuticle and the nail matrix. The area may become swollen, red and tender. Acute paronychia is an usually due to bacterial infection, particularly Staphylococcus aureus. Chronic paronychia may be associated with eczema or psoriasis. It is often due to Candida infection but other pathogens, e.g. Pseuodomonas (produces a green or black discolouration) may be the cause.

Acute paronychia

Erythema, swelling and throbbing pain in the nail fold caused by bacterial infection, e.g. Staph. aureus and group A Strep.

Chronic paronychia 

·               Commonly occurs in patients whose hands are constantly in water with repeated minor trauma damaging the cuticle so that irritants can further damage the nail fold.

·               Proximal and lateral nail folds show erythema and oedema with loss of cuticle and part of proximal nail fold separating from nail plate.

·               Commonly becomes infected especially with C. albicans. Eventually nail fold retracts becomes thickened and rounded.

·               There are episodes of painful acute inflammation often due to infection between the proximal nail fold and nail plate from which pus may drain.

·               Over time, lateral edges of nail plate become irregular and discoloured and eventually entire nail plate becomes involved showing numerous transverse grooves.

·               Treatment is to remove source of irritation, topical steroids and weekly doses of fluconazole.