Nail Findings: Small Clues, Big Diagnostic Value

Nails can offer important clues about patient health. Changes in color, shape, texture, or growth may be linked to infections, inflammatory skin conditions, systemic disease, nutritional deficiencies, medication effects, or even malignancy.

Because nail disorders can be varied in appearance, recognizing key patterns is important. Common conditions such as onychomycosis and acute paronychia can usually be identified by characteristic findings, while changes such as clubbing or koilonychia may point to underlying systemic disease, and nail dystrophies, such as trachyonychia or pitting may point an associated dermatologic conditions.

Case Example:

A 34-year-old woman presents to your clinic with fingernail concerns. Over the past few months, she has developed “tiny dents” in some of her fingernails. On examination, you see that several of her nails are pitted. You know that persistent nail changes can be associated with several conditions. Your initial differential diagnosis may include:

•  Psoriasis – Around 80%-90% of patients with psoriasis display nail manifestations at some point in their lifetime. Pits from psoriasis are usually large, deep, and irregular and seldom observed on toenails.

• Alopecia areata – Onychodystrophy impacting some or all nails is a common association. Pits are classically shallow and are arranged in a grid-like pattern, although irregular pitting may be observed.

• Atopic dermatitis – Chronic inflammation from periungual eczema can affect the nail matrix, disrupting normal keratinization and causing pitting as the nail grows out. Pits may be superficial and irregular.

• Lichen planus – Clinical features depend on the location, duration, and severity of the disease in the nail apparatus. Focal nail matrix involvement produces longitudinal splitting, longitudinal ridging, and pitting.

Although they occupy a relatively small area of the physical examination, nails can provide valuable information that supports earlier recognition of disease and a more complete understanding of a patient’s overall health.

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