16 - Nails Flashcards
Anatomy of the nail
Nail Plate: Hard, translucent, dead keratin
Nail fold: surrounding skin and matrix
Matrix: Matrix epithelium synthesizes the nail plate
Lunula (white 1/2 moon): distal aspect of nail matrix, continuous w nail bed
Nail bed: consists of parallel longitudinal ridges w small blood vessels at their base
Hyponychium: short segment of skin lacking nail cover
Pic on slide 5
What is the MC effect of psoriasis on the nail?
Pitting (MC)
What effects does psoriasis have on the nail?
Pitting (MC)
Onchyolysis
Oil spots
Gross deformity (fragmentation, crubmling, and splinter hemorrhages)
What is onchyolysis?
Onycholysis is the painless separation of the nail from the nail bed.
This is a common problem. It can be a sign of skin disease, an infection or the result of injury, but most cases are seen in women with long fingernails.
Treatment for psoriasis?
Systemic:
- cyclosporin
- methotrexate
- aceitretin
Topical
- intralesional kenalog
- calcipotriol ointment (vit D)
- tazaroten gel (retinoid)
- anthralin ointment (MOA UKN)
If a pt has nail lichen planus (LP)?
They prob have it elsewhere too
- 25% have it more places
MC findings for LP?
Longitudinal grooving and ridging
Inflammation of the matrix with LP may cause?
Adhesion of the proximal nail fold to the scarred matrix (pterygium unguis)
LP tx?
Self limiting but:
Local
- intralesional kenalog
Systemic
- oral prednisone
What types of drugs effect the nail?
Chemotherapy drugs are associated w variety of changes in the nail unit
Tetracycline abx can also do it
Tinea of the nails is aka?
Tinea unguium
- its is a type of onchomycosis
Presentation of tinea unguium?
May occur simultaneously w hand/foot tinea or alone
Thickened yellow nails
- may look like psoriasis too
How to confirm onchomycosis?
KOH and CX to confirm species before treating
Cx - crumbling debris from under distal edge
Patterns of infection for oncychomycosis?
Distal subungual onychomycosis
White superficial onchomycosis
Proximal subungual onchomycosis
Oral Treatment for onychomycosis?
Oral agents
- Terbinafine (lamisil) 250mg q Day x 12 wks
- itraconazole (sporanox) 200mg q day x 12 wks
- fluconazole: 450 q week x 3 months
- griseofulvin (Gris-PEG)
Preferred txt for onchomycosis?
Terbinafine
- higher cure rate
- slower relapse rate
- not many drug interactions
- results last >2 yrs
Topical tx for onychomycosis?
Ciclopirox nail lacquer (PENLAC)
- for use w/o lunula involvment
- complex implementation
Efinaconazole (jublia)
- shitty cure rate (16-53%)
Prevention for onchomycosis?
Shoes/boots - protect toes from trauma Dont pick nails Rotate footwear Clean socks Shower shoes Keep nails short
What is chronic exposure (in reference to nails)
Repeated water immersion or Frequent use of nail polish removers
Leads to brittle nails
Chronic exposure txt?
Rehydrate the nail Moisturizer/lubricant Protective gloves Nail enamel weekly B-complex vitamin (biotin B7)
Types of nail trauma
Oncholysis Nail biting Hang nail Ingrown toenail Subungual hematoma Habit-tic deformity
What is a hangnail?
Skin separation form lateral nai folds
- esp during winter months
Txt for hang nail?
Cut separated skin before it extends
Use moisturizers
Avoid repeated hand immersion in water
Txt for onycholysis?
Removal of separated nail
Ingrown toenail rundown?
Large toe (usually)
Nail pierces nail fold and becomes FOB
Swelling, pain, purulent drainage
Causes of ingrown toenail?
Poorly fitting shoes
Bad nail care
Acute trauma
Txt for ingrown nail?
Partial/full nail removal
- phenol may prevent recurrence
What is a subungual hematoma?
Trauma to nail plate
- immediate bleeding
- pain
- self limiting
Sever subungual hematoma txt?
Trephination ASAP
Field expedient method
- heated paperclip to melt a small hole
- you can also use an 18g needle
What is habit-tic deformity?
Caused by biting or picking a section of proximal nail fold of thumb w index fingernail
Defect Consists of
- longitudinal band of horizontal grooves w yellow discoloration
If you see habit-tic deformity the pt may suffer from?
Psychiatric d/o
- OCD
Txt for habit-tic deformity
Stop being crazy
What are pincher nails?
Inward folding of lateral edges
- painful
- prob 2/2 shoe compression
Txt for pincher nails?
Removal
Shoes w wider toebox
What is acute paronychia
Bright red swelling of proximal and lateral nail fold
- rapid onset
Small abscess
Acute paronychia follows?
Trauma
Nail biting
Manipulation
Txt for acute paronychia?
Drainage of abscess
Antistaphylococcal abx
The way i’ve seen it treated is gently seperate the skin from the nail w an 18g needle, get a little puss out and squeeze the shit out of it
- the pt is not usually happy
What is chronic paronychia
Chronic inflammation of proximal nail fold
- sig contact irritant exp is maj cause
Gets colonized with candida
What fingers are involved w chronic paronychia?
Typically its many or all of them
Txt for chronic paronychia?
Avoid exposures
Tx underlying inflammation/infection
Fluconazole if bad
How does one get pseudomonas in their nail?
Onycholysis exposes a damp, macerated space
- leads to growth of pseudomonas
Describe pseudomonas nail
Nail plate turns green-black in color
Txt for pseudomonas nail?
Mix of
- chlorine bleach
- water
Or
- vinegar
Or
- ciprofloxacin if severe/txt failure
What are beau’s lines
Transverse depressions of all nails
- appears at base of lunula
- weeks after stressful event
Prognosis and txt of beaus lines?
Nothing, they grow out normally
What is yellow nail syndrome?
Rare syndrome
Nail plate becomes
- curved
- yellow
Usually involves all nails
When does yellow nail syndrome occur
Seen before, during, or after A respuratory disease
AIDS pts
Txt for yellow nail syndrome?
May spontaneously resolve
Vitamin E (oral or topical) helps
What causes finger clubbing?
Normal variant Heart disease Lung disease Colitis Thyroid disease
What is lovibonds angle?
A method of measuring the nail to determine if a finger qualifies as “clubbing”
> 180* is pos
160* is normal
Txt for clubbing?
Nothing its permanent
What is koilonychia?
Spoon nails
What are spoon nails?
Lateral elevation and central depression of nail plate
- may be normal
- may be IDA
Txt for spoon nails?
Treat the anemia
What are mee’s lines?
Transverse white line in the nail plate
What causes mee’s lines
Sepsis Renal failure Arsnec poisoning Hepatic failure CHF Chemo
Txt for mee’s lines?
Txt: Underlying problem
Nail grows out w nail and resolves
what do you call a sleeping bull?
A bulldozer
