Nails

Question 1

If this disappeared when pressed, what systemic problem may be present?

Answer 1

Hypoalbuminemia (apparent leukonychia)

Question 2

Name 3 diseases that may cause this finding.

Answer 2

Lupus

Scleroderma

Dermatomyositis (then need to screen for CA!!)

(This is cuticular hemorrhaging, which is a sign of autoimmune connective tissue disease)

Question 3

Most common cause?

Answer 3

Trauma (Beau’s lines)

Question 4

Condition?

Answer 4

Candidal onychomycosis

Question 5

You had this finding in someone who was recovering from surgery. Dx?

Answer 5

PE (clubbing is commonly due to cardiopulmonary disease)

Question 6

Where would you look to distinguish the cause of this finding?

Answer 6

Extensor and flexor surfaces

(Irregular pitting = eczema and psoriasis; flexor = eczema; extensor = psoriasis)

Question 7

What general disease process may be underlying this finding?

Answer 7

Autoimmune connective tissue disease

(cuticular hemorrhage)

Question 8

Finding illustrated here?

Answer 8

Pitting - abnormal matrix production that moves distally with nail growth

Question 9

Which part of the nail plate is affected by this disease?

Answer 9

Ventral (bottom) nail plate

(Distal subungal onychomycosis)

Question 10

Nail finding?

Answer 10

Koilonychia

(This is hypochromatic microcytic anemia, the most common cause of which is iron deficiency anemia)

Question 11

Skin histology of this disease would reveal:

Answer 11

Inflammation at the dermal-epidermal junction

(This is lichen planus - scarring of nail fold over nail + fissuring of nail plate)

Question 12

Histology of this condition would reveal:

Answer 12

Granulation tissue

(Onychocryptosis - ingrown nail)

Question 13

Name 4 findings on this nail and the disease for which these are characteristic

Answer 13

Eczema

1. Paronychia
2. Subungal hyperkeratosis
3. Irregular pitting
4. Trachyonychia

Question 14

Demographic in whom this finding is most common?

Answer 14

Kids

(Geometric pitting = alopecia areata)

Question 15

If this patient had this finding since childhood, what testing could be done to distinguish the underlying cause?

Answer 15

Filaggrin mutation

(Irregular pitting = eczema or psoriasis; childhood points to eczema; congenital eczema due to filaggrin defect)

Question 16

How would the organism cultured from this nail appear on gram stain?

Answer 16

Pointed ends

(P. aeruginosa)

Question 17

Cause?

Answer 17

Pyocanin secretion by P. aeruginosa

Question 18

Dx?

Answer 18

Myxoid cyst

(Swelling of nail fold + depression on nail plate + grooves in nail plate)

Question 19

Tx?

Answer 19

Iron supplementation

Question 20

First step in management?

Answer 20

UA/LFT

(Lindsay’s nails - half and half apparent leukonychia; points to CKD)

Question 21

First step in management?

Answer 21

Biopsy for melanoma

(Single longitudinal melanonychia points to melanoma)

Question 22

Name of this measurement? What does it suggest? What other sign related to this finding would you expect to be abnormal on physical exam?

Answer 22

Lovibond’s angle; >180 degrees suggests cardiopulmonary disease; Shamroth sign

Question 23

Demographic?

Answer 23

Elderly

Question 24

If this persists when the nail is pressed, two causes?

Answer 24

Arsenic or thallium poisoning

(True leukonychia)

Question 25

This patient may have what type of mutation?

Answer 25

BRAF (Hutchinson's sign = longitudinal melanonychia runs onto nail fold = melanoma)

Question 26

Name of this finding? Other related finding?

Answer 26

Muerckle's lines Edema (Apparent leukonychia; hypoalbuminemia)

Question 27

This "bump" may be attached to:

Answer 27

DIP (Myxoid cyst)

Question 28

Dx?

Answer 28

Psoriasis (Onycholysis with erythematous nail beds)

Question 29

Factors predisposing to this condition?

Answer 29

Hyperhidrosis, congenital misalignment, improper clipping

Question 30

Demographic?

Answer 30

African Americans (90%) (Longitudinal melanonychia)

Question 31

Name of condition? Cause?

Answer 31

Onychogryphosis - asymmetric nail growth

Question 32

4 disease which can cause this finding

Answer 32

1. Psoriasis 2. Onychomycosis 3. SCC 4. Warts (Onycholysis)

Question 33

Tx?

Answer 33

Cisplatin (SCC)

Question 34

Tx?

Answer 34

Antipsychotics (Onycotillomania - tic)

Question 35

Cause?

Answer 35

Compulsive tic

Question 36

Dx?

Answer 36

Subungal exostosis (Bony proliferation seen on X ray)

Question 37

Dx?

Answer 37

Eczema (Irregular pitting + paronychia)

Question 38

Your patient presents with this finding 5 times in the past two years. First step in management?

Answer 38

Check for HSV (Remitting paronychia - HSV)

Question 39

First step in management?

Answer 39

Check for tuberous sclerosis (Periungal fibroma - associated with tuberous sclerosis)

Question 40

Causes?

Answer 40

Congenital or ill-fitting shoes

Question 41

Finding?

Answer 41

Punctant true leukonychia

Question 42

Benign or malignant?

Answer 42

Bening (Pyogenic granuloma = bleeding angiomatous nodule)

Question 43

Mutation? Potential other causes?

Answer 43

p53, HPV/immunosuppression/chronic inflammation (SCC)

Question 44

A kid with this finding may have recently had what other illness?

Answer 44

Staph infection (Splinter hemorrhage - infective endocarditis - most commonly caused by S. aureus in kids)

Question 45

Cause?

Answer 45

Bony proliferation (Subungal exostosis - benign tumor)

Question 46

How to tell this from a melanoma?

Answer 46

This is a subungal hematoma, which will migrate distally with nail growth

Question 47

Most common cause?

Answer 47

Cirrhosis (Terry's nails - few millimeters of brown-red distally - apparent leukonychia)

Question 48

Causes?

Answer 48

1. Lichen planus 2. Psoriasis 3. Eczema 4. Alopecia areata (Trachyonychia)

Question 49

This can be caused by which serotypes of HPV?

Answer 49

2.4 (Common warts)

Question 50

Cause?

Answer 50

Fungus (White superficial onychomycosis)