Nail Changes Flashcards
Causes of nail destruction
-Psoriasis
-Lichen planus
-Immunobullous disease
-SCC/ melanoma
What is onycholysis and what causes it?
-Separation of the distal nail from the nail bed. It is frequently a useful diagnostic sign.
=Psoriasis
=Dermatophyte infection
=Trauma
=Thyroid disease (rare)
What is pitting and what causes it?
-Occasional focal depressions are seen in normal individuals but pits are a feature of
=Psoriasis
=Eczema
=Lichen planus (when you see so much ‘stippling’ it looks distinctive and has the name trachyonychia
=Alopecia areata
-The actual pits consist originally of foci of parakeratosis in the dorsal nail matrix, which then fall out when the nail moves forward.
What are ridges?
-These can be either longitudinal or transverse, and they often occur without an explanation, but may be seen in eczema, psoriasis or fungal disease. They are often irregular and not as ‘tidy’ as the horizontal lines
What are horizontal lines: Mees Lines, Beau-Reil grooves?
-Changes to nail growth= interruption or disturbance of the growth of the nail in the nail matrix.
=One or more ‘tidy’ convex bands of disturbance.
=Sometimes the disturbance is just of colour (often keeping the colour of the lunulaas in Mees lines);
=Fine ‘crack’ or deep ridge as in Beau’s lines / Beau-Reil grooves.
-A single line on a nail might be due to trauma, but multiple regular lines, on multiple nails may reflect the pattern of administration of chemotherapy
What is a myxoid cyst?
-Most commonly seen on the hands, immediately proximal or above the dorsal nail matrix, and represents the cystic outgrowth from the distal joint.
-Gelatinous material can be expressed from the cyst if ruptured with a needle.
-Pressure from the cyst causes nail dystrophy due to pressure on the dorsal nail matrix.
-If it is symptomatic the best treatment is surgery
What is koilonychia?
-Spoon like nails sometimes seen in iron deficiency.
-It can also be seen in normal individuals
What causes green nails?
-Colonisation by pseudomonas aeruginosa, which produces a greeny-black pigment.
-Treat with topical antibacterials (systemic not needed).
What is melanonychia?
-Presence of a brown longitudinal streak in the nail.
-Very common in people with dark skin and the lesions are often multiple.
-In lighter skinned individuals melanonychia is less common and the concern is whether the pigmentation reflects either a benign nevus or a melanoma in the dorsal nail matrix.
-If there is pigmentation in the nail fold (Hutchinson’s sign) the likely cause is a melanoma.
-Investigation often will involve exposure of the dorsal matrix and biopsy under ring-block anaesthesia.
-There is sometimes an inappropriate reluctance to perform such surgery, but missing melanoma is a big concern.
What causes blue black nail?
-Most commonly due to a haematoma but the differential is a melanoma.
-Not all patients with a haematoma are able to recall an episode of trauma.
-Hutchinson’s sign (pigmentation of skin around the nail) strongly points towards melanoma.
-Spread of pigmentation from a nail to the surrounding skin is a red-flag sign, and many patients with proven subungual haematomas give no history of trauma. Conversely some patients with subungual melanomas attribute their lesions to trauma.
=Nail biopsy
What is Paronychia?
-Inflammation around the nail.
-It is usually the result of acute or chronic infection gaining access via an abnormal cuticle, such as you see in eczema, or in individuals whose hands are frequently exposed to water or solvents
Describe acute paronychia
-Hallmarks of an acute staphylococcal infection (pain, swelling, erythema, pyrexia possibly) which is usually treated with systemic anti-staphylococcal antibiotics if it is severe.
-Occasionally surgical drainage may be required
Describe chronic paronychia
-Frequently seen in atopic individuals or those with continued industrial exposure of the hands.
-The aetiology is unclear.
-It may well be that chronic candida infection plays a role but sometimes the disease seems to respond to corticosteroids alone.
-Topical anti-candida agents with or without steroids may be used.
-The central aim is to try and remove the cause by not exposing the hands to chronic trauma and irritants, otherwise attacks will be recurrent.
