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#2 Derm > 16 - Nail Manifestations of Systemic Disease > Flashcards

16 - Nail Manifestations of Systemic Disease Flashcards

1
Q

Introduction

A
  • Nails can be a first sign in detecting a systemic disease

- “Pathological processes responsible for most nail changes are unknown”

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2
Q

Normal nails

A
  • Thin, shiny, firm
  • Melanonychia (black streak) common in African-Americans
  • Aging nails lose luster, thicken and become yellow
  • Longitudinal ridging occurs with aging
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3
Q

Abnormalities in color, shape and texture of the nail may reflect…

A
  • Abnormality of nail, itself
  • Abnormality of subungual area
  • Abnormality of periungual area
  • Systemic disease
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4
Q

Anonychia

A

Anonychia: absence of nail, seen in alopecia areata and nail-patella syndrome

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5
Q

Brittleness

A
  • Brittleness: normal nail contains 18% H2O in the form of vapor
    o Normal aging loses this H2O and nail growth rate decreases
    o Keep nails short and moisturize at night

*** (all underlined)

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6
Q

Clubbing

A
  • Clubbing: loss of the normal angle between the nail and the posterior nail fold-later the distal phalanx becomes enlarged and there may be an increase in the size of the nail
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7
Q

Etiology of clubbing

A

o Result of an angulation of the matrix secondary to an increase in connective tissue (increased circulation?) – distal end of matrix is high compared with the proximal end *
o Most common cause is lung disease (bronchiogenic CA) ***

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8
Q

Schamroth’s test

A

o Schamroth’s test is positive-when the two index fingers are put nail to nail, there is a loss of the normal diamond-shaped recess between the base of the nail plates; there is also an increase in the length of the “V” at the tip of the plates

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9
Q

Chromonychia

A
  • Color changes (Chromonychia): can be altered by external stains (nicotine), partial destruction, abnormal formation
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10
Q

White nail

A

White nail (Terry’s nail)-hepatic cirrhosis-disease of nail bed and not nail plate

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11
Q

Muehrcke’s lines

A

Paired, narrow white bands that run parallel with the lunula and are separated from one another and from the lunula by areas of normal pink nail-hypoalbuminemia-changes not in nail plate

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12
Q

Mee’s lines

A

Mee’s lines-punctate or striped white bands associated with arsenic poisoning

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13
Q

White nail (leukonychia)

A

White nail (leukonychia): in nail plate, itself (partial leukonychia is very common)

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14
Q

Blue-green nail

A

Pseudomonas, subungual hematoma

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15
Q

Red half-moons

A

Congestive heart failure

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16
Q

Blue half-moons

A

Hepato-lenticular degeneration (Wilson’s disease)

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17
Q

Half-and-half nail

A

Half-and-half nail (proximal nail bed is white and the distal half red, pink, or brown)
o Renal disease and azotemia

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18
Q

Black streak

A

o Think Melanoma, common and normal in African-Americans
o Multiple streaks common in Addison’s disease
o Most common cause of blackened toenail is a subungual hematoma due to trauma

If diagnosis uncertain, remove nail and perform superficial shave biopsy of lesion. Submit both shave and nail for pathology

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19
Q 
Mee’s lines are associated with:
o	Cardiac disease
o	Pulmonary disease
o	Hypoalbuminemia
o	Arsenic poisoning
o	Renal disease
A

Answer: 4 – Arsenic poisoning

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20
Q

ABCDEF of Subungual Melanoma

A
  • African-American, Native American, Asian
  • Band is brown-black, breath is > 3mm, border is irregular
  • Change is rapid in size or growth rate
  • Digit-hallux
  • Extension into surrounding skin (Hutchinson’s sign)
  • Family or personal history of melanoma or dysplastic nevus syndrome
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21
Q

Yellow nail syndrome

A

Yellow nail syndrome: nails cease, or almost cease, to grow and some months later take on a yellow color-nails remain smooth, but may be excessively curved form side to side, the lateral margins are less covered by soft tissue, cuticle is deficient-may have a distinct hump
o Bronchiectasis, bronchitis, pleural effusion

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22
Q

Subungual hemorrhage

A

Subungual hemorrhage: bleeding of nail bed
o Trauma
o Psoriasis, eczema, fungus

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23
Q

Hypertrophy

A 
o	Trauma (little toe normally thickened due to chronic nail pressure)
o	Psoriasis, fungus, eczema, Darier’s disease
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24
Q

Koilonychia

A
  • Koilonychia:”spoon-shaped” nail (concave dorsally)-distal end of nail depressed below its normal level due to anoxia and atrophy of the distal connective tissue
  • Iron-deficiency anemia
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25
Q

Oncholysis

A 
-	Onycholysis: separation of nail from its bed
o	Psoriasis, fungal infection, eczema
o	Impaired peripheral circulation	
o	Thyrotoxicosis
o	Yellow nail syndrome
o	Trauma
26
Q

Parrot beaking

A
  • “Parrot beaking”: nails look like a beak curving around the atrophic soft tissue of the tips of the toe (convex curve)
  • Scleroderma, normal, TB
27
Q

Pitting

A
  • Pitting: pits are due to retention of nuclei (parakeratosis) in parts of the nail keratin-these areas are weaker than surrounding normal keratin and may be shed leaving the pits on nail surface
  • psoriasis, eczema, fungal infections, alopecia areata
    o may be quite normal
28
Q

Pterygium formation

A

Pterygium formation: cuticle appears to grow forward on the nail plate and the nail is split into two portions; results from fusion of epidermis of the dorsal nail fold to the nail bed and matrix
o Impaired circulation
o Lichen planus

29
Q

Shedding

A

Shedding: nail loss may be result of loosening at the base (onychomadesis) or separation from the nail bed (onycholysis)
o subungual hematoma
o yellow nail syndrome
o severe illness, drug reaction

30
Q

Shedding with scar formation

A 
o	trauma
o	impaired peripheral circulation
o	lichen planus
o	epidermolysis bullosa
o	bullous drug eruptions
31
Q

Splinter hemorrhages

A

Splinter Hemorrhages: longitudinal, thin black lines of hemorrhaging below the nails
o Classic association with subacute bacterial endocarditis
o Psoriasis, fungal infections, eczema, minor trauma, RA, mitral stenosis, peptic ulceration, malignant neoplasm

32
Q

Causes of longitudinal striations

A

o Common in healthy persons – most important*
o Lichen planus – most important*
o Other causes – Darier’s disease, impaired peripheral circulation, RA
o Single depression through length of nail may be seen in median dystrophy, habit tic, mucous cyst

33
Q 
-Pterygium formation is seen with:
o	Psoriasis
o	Lichen planus
o	Eczema
o	Clubbing
o	Reiter’s disease
A

Answer: 2 – Lichen planus

34
Q

Median nail dystrophy

A
  • Median nail dystrophy: unknown etiology-slightly off-centered split with feathery cracks extending laterally from the split (“inverted fir tree”)-may return to normal
35
Q

Causes of transverse striations

A

o Eczema
o Habit tic
o Raynaud’s phenomenon
o Single depression may be a Beau’s line: disability which temporarily interferes with the rate of growth of the nail including measles, mumps, pneumonia, coronary thrombosis, chemotherapy

36
Q

Causes of thinning

A

o Impaired peripheral circulation
o Lichen planus
o Epidermolysis bullosa
o Iron deficiency anemia

37
Q

Appearance of nails in psoriasis

A

o Most common disease associated with pitting*****
o Partial onycholysis, starting at free edge
o Opaque, discolored, irregular, thickened, pustular
o Formation of hyperkeratosis at the free edge
o Over-curvature
o Arthropathy

38
Q

Appearance of nails in eczema

A

o Most common is atopic or contact dermatitis which leads to atrophic changes
o Irregular ridges across nail, pitting, subungual hemorrhage
o Gross hypertrophy and onycholysis occur less frequently

39
Q

Appearance of nails in lichen planus

A

Lichen planus: nail changes occur in 10% of patients with skin disease
o Most common change is longitudinal ridging with slight depressions of the surface
o Thinning, pterygium formation

40
Q

Appearance of nails in Reiter’s syndrome

A

Reiter’s syndrome: nail changes develop with keratoderma blenorrhagicum lesions
o Indistinguishable from psoriatic nails

41
Q

Appearance of nails in scleroderma

A

Scleroderma: changes primarily due to impaired peripheral circulation
o ”Parrot beaking”

42
Q

Appearance of nails in SLE (lupus)

A
  • Cuticles broken with hemorrhagic lesions in the area
43
Q

Appearance of nails in dermatomyositis

A

Patches of erythema with telangectasia over the posterior nail fold, erythema over toe joints

44
Q

Appearance of nails in pemphigus or epidermolysis bullosa

A

Shedding of nails with nail bed scarring

45
Q

Appearance of nails in sarcoidosis

A

Thickened, irregular with damage to distal phalanx

46
Q

Appearance of nails in scabies

A

o Thickened and opaque

47
Q

Nail changes due to chemotherapy

A 
Cancer chemotherapy (seen 3 to 10 weeks into treatment)
o	Beau’s lines
o	Pigmentary changes
o	Onychomadesis
o	Transverse leukonychia
48
Q

Effect of Accutane (drug) on nails

49
Q

Effect of tetracycline and doxycycline on nails

A

Photosensitive onycholysis

50
Q

Benign tumors which can cause nail changes

A
  • Verruca
  • Herpes simplex
  • Mucosal cyst
  • ***Glomus tumor
  • Pyogenic granuloma
  • Subungual exostosis
  • Periungual fibrokeratoma
51
Q

Glomus tumor

A

Glomus tumor associated with EXTREME localized pain under a fingernail or toenail
o May or may not have the bluish discoloration
o You can mimic the pain by pressing on the one focal area (with toothpick or pen)
o You will need to go in and remove this tumor

52
Q

Subungual exostosis

A

Subungual exostosis – does NOT start as bone growth, rather a soft tissue growth which ossifies

53
Q

Malignant tumors which cause nail changes

A
  • Melanoma
  • Squamous cell CA
  • Epithelioid sarcoma
  • Bazex’s syndrome (acrokeratosis paraneoplastica)
54
Q

**Amelanotic melanoma **

A
  • Amelanotic melanoma: nail bed melanocytes are the least numerous and do not synthesize melanin
  • “THIS IS WHAT I’M SCARED TO DEATH TO MISS”
  • Loves the hallux
55
Q

Nail changes seen in cardiovascular and hematologic disease

A
  • Splinter hemorrhages

- Red lunula

56
Q

Nail changes seen in GI disease

A
  • Terry’s nail
  • Blue half-moons
  • Brown nails of hyperbilirubinemia
  • Chronic hepatitis may cause splinter hemorrhages, clubbing, and white nails
57
Q

Nail changes seen in renal disease

A
  • Half-and half nail (Lindsay’s nail)
  • Anonychia
  • Longitudinal ridging
  • Koilonychia
  • Muehrcke’s lines
  • Increased red color in renal adenocarinoma due to increased erythropoeitin
58
Q

Nail changes seen in pulmonary disease

A
  • Yellow nail syndrome

- Clubbing

59
Q

Nail changes seen in endocrine disease

A
  • Longitudinal pigmented bands in Addison’s disease
  • Short, wide, thick, flat nails in acromegaly
  • Proximal nail bed telangiectasia with yellow nails in diabetes
  • Brittle nails with longitudinal sulci in hypothyroidism
60
Q 
A thick, dystrophic, yellow nail can be seen  with all of the below, EXCEPT:
o	Lichen planus
o	PVD
o	Psoriasis
o	Trauma
o	Hypoalbuminemia
A

Answer: 5 – hypoalbuminemia

61
Q

FOCUS ON…

A
  • Systemic disease that causes disease
  • Know the nails that have color changes but DO NOT NEED to know color changes with DRUGS
  • DON’T need to know the entire list of things in which they are associated
  • I have indicated the major ones that you need to know
  • There will be pictures, but there will be enough clinical information in the text

#2 Derm (13 decks)

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