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Nailing Your Diagnosis: The Hand Exam

By Jacob Mathew, Jr., DO, FACOI, FACP, CHSE, FAWM

Unless otherwise stated, all treatments and doses are for adults and not weight based for the pediatric population.

Case Example:

A 48-year-old female patient presents to your clinic for abnormal findings in her toes. She knows that the summer season is coming up and the abnormal appearance of her toenails is very concerning to her. She is a regular patient to your clinic, routinely seen for type 2 diabetes mellitus that is poorly controlled.

Let’s review some anatomy (Scher RK)

If you were to look at the cross section of your digit, you would see that the nail bed is covered by the nail plate. The most proximal portion of the nail bed is the blood supply and the growth region, called the nail matrix, which provides the epithelial cells for nail plate growth. When it comes to the conditions discussed in this review, damage to the matrix is key in causing many of the irregularities experienced: longitudinal lines, roughness, pitting, brittleness, and transverse lines. Overlying the nail on the proximal end is the cuticle (skin). On either side (lateral) of the nail are the nail folds. Just below the nail bed is the distal phalanx and periosteum. Due to the close proximity, any condition that affects the bone can affect the nail, and vice versa.

Important Conditions Associated with Abnormal Nail Exam

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Psoriasis

Can manifest with nail pitting, leukonychia, and an oil drop sign on the nail bed. Look for cutaneous psoriasis as a coexisting feature.


 

 

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Paronychia

Can present acutely or in a chronic manner with tender, erythematous swelling and folding on the lateral portions of the nail. Treat with warm saline soaks and, if a concurrent abscess is present, possible drainage with antibiotics targeted to Staphylococcus aureus (if acute) and gram negatives with Candida (if chronic).  (Rigopoulos D, 2008)



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Splinter hemorrhages

Classically associated with subacute bacterial endocarditis; they can be seen with vitamin C deficiency as well.




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Clubbing

Classically associated with severe pulmonary disease (COPDlung cancer) causing hypertension and a chronic state of hypoxia; can also be associated with inflammatory bowel disease. Look for painless bilateral enlargement of the nail fold angles of all fingers and toes and a positive Schamroth sign. Consider testing HIV, TSH, LFTs, and CBC. Treatment is centered on the underlying cause. (Chumley HS)


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Beau Lines

Presents as transverse grooves or furrows in the nail. Generalized causes include medication side effects (ie, retinoids for acne), liver/cardiac/renal failure, carpal tunnel if present on only one extremity, postsurgical complication from tourniquet use, and regional pain syndrome. If only one or a few digits are involved, hand-foot-and-mouth disease should be considered. (LeBlond RF)

 

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Mees' Lines

Also known as transverse white nail lines, can be seen during periods of stress, renal failure (acute), heart failure, inflammatory bowel disease, SLE, and malignancy. In the right clinical setting, consider toxic metal exposure (ie, thallium). (Lipner SR, 2016)

 

 

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Hutchinson Sign 

Melanoma in situ manifesting as a pigmented linear line (brown to black) from the matrix to the perionychium and typically a poor prognostic indicator as it could represent radial-growth phase melanoma. Such bands, which typically have a sudden onset and growth, often affect only a single digit (commonly the thumb). Such patients, who are typically in their 60-80s with a family history of melanoma, should be referred to a dermatologist for dermoscopy to be performed with biopsy. (Lipner SR, 2016)

Is there a structured way to approach nail conditions?

The easiest way to approach the differentials is by splitting them into two categories: localized nail conditions and systemic, which can be a harbinger for another underlying condition. Next, when dealing with localized conditions, understanding the anatomy of the nail bed can further help distinguish conditions. Another way to look at these conditions is by determining what part of the matrix is involved.

How to approach the history and exam

Knowing the anatomy above is crucial. Furthermore, patients should be instructed, ideally by your staff prior to their visit (if in the outpatient setting), to remove any nail polish present. If you would like to document changes over time, utilize your local hospital or clinic policy for taking photographs to include in the clinical record. Understand that regardless of sex, race, or ethnicity, the nail bed color is identical. Therefore, any preserved discoloration may be pathological or physiologic and should not be attributed to normal variants. (Jefferson J).

The following social and familial historical elements are helpful in creating a differential diagnosis:

  • Occupation
  • Exposures to topical substances
  • Medication history
  • Smoking or tar use
  • Illicit drug history
  • Family history of similar findings/concerns

 When it comes to the specific complaint, it is important to know the following information:

  • How many digits are affected and whether the condition spread or affected all digits at once
  • History of trauma to the affected digits
  • Any recent stress
  • Whether or not all the nails appear similar

Are all abnormal appearances to the nail suggestive of disease? (Mayeaux)

No; There are normal nail variants that every clinician should be aware of (see table below for those that may be associated with underlying systemic disease). Many times, these variants are associated with a disruption in nail formation. Many patients think that abnormalities in the nails, even if they are normal variants, are suggestive of an underlying vitamin deficiency. It is important to reassure these patients as to which findings are concerning based on your exam and which are not.

  • Transverse striate leukonychia – Also known as transverse white streaks, these can be seen in a healthy patient and are not suggestive of underlying pathology. The best way to distinguish these is by looking at the lateral most portion of the nail, as these streaks will not extend to the lateral most portion of the fold.
  • Nail hypertrophy – Development of opaque thickened nails, also called ram’s horn nail, that can occur with age, fungal infections, and trauma. Typically asymptomatic; however, pain may occur if pressure is placed directly onto the nail.
  • Habit-tic deformity – Habitual picking of the proximal nail fold can result in secondary inflammation and damage to the nail plate, leading to a ridged appearance.
  • Beau lines – Discussed extensively above and below, can occur with trauma or severe illness when of pathologic origin.
  • Lindsay nails – Also known as half-and-half nail, the proximal portion of the nail is white and the distal portion is pink, with a sharp demarcating line between the two halves. Can be seen also in patients with cirrhosis and HIV.

Is this a vitamin problem? (Seshadri D, 2012)

The nail itself requires myriad nutrients to stay healthy. Most vitamin deficiencies are due to either inadequate dietary intake or malabsorption. Vitamin D, which can be obtained through sun exposure, is one of the few exceptions. Lack of these nutrients may affect the nail, the nail bed, or both and may present on physical exam or with biopsy. Common conditions we experience in the primary care setting, such as iron deficiency and magnesium deficiencies in alcoholic patients, can affect their concentrations, or lack thereof, in the nail. Below, we will discuss common nail findings associated with malnutrition and vitamin/mineral deficiencies.

Nutrition deficiencies

  • Beau lines – Associated with protein deficiencies in chronic alcoholics. Present as transverse depressions in a linear fashion of the nail due to disruption in the growth of the nail.
  • Terry nails – Seen in those with cirrhosis and malnutrition. When looking at the proximal nail bed, it will appear as a pink or brown band.
  • Muehrcke lines (Pfeiffer C, 1974) – Patients with chronically low albumin and/or zinc levels may develop this exam finding; correction of albumin levels (< 2.2 g/mL) will lead to resolution of the findings. Look for narrow, white transverse linear bands that disappear if you press down on the distal portion of the nail.
  • Brittle nail syndrome – Those who are chronically malnourished can develop brittle nail syndrome, which presents with soft, weak, and easily breakable nails that form longitudinal splits. In your younger patients who present with this, ask about disordered eating habits that may reveal underlying anorexia. In your elderly patients, this may be a sign of dementia.

Vitamin and mineral deficiencies

  • Iron deficiency (Ghaffari S, 2018) (Adhikari, 2018) – Commonly seen in the primary care setting, iron deficiency can cause koilonychias, presenting as a reverse curvature of the nail bed due to the effects that a lack of iron has on the distal matrix. This isolated effect on the distal,  rather than proximal, matrix causes the nail to grow in a downward direction. In post-gastrectomy patients who are at risk for malabsorption, remember that koilonychias may be a sign of deficiencies if routine testing (CBC with mean corpuscular volume [MCV] level) are not abnormal.
  • Selenium deficiency (Hasunuma N, 2014) (Tonelli M, 2015) – Found in poultry, milk, wheat, and potatoes, selenium is mostly obtained through plants due to its presence in the soil. Deficiency can be seen in vegetarians who consume food where the soil is deficient in selenium. In first world countries, can be observed in those on both hemodialysis and peritoneal dialysis or inflammatory bowel disease. On exam, look for opaque, whitened nail beds.
  • Calcium deficiency (al., 2015) – Transverse white bands along multiple nails in the relatively same position can occur with calcium deficiencies, but they are reversible with treatment. Measuring the distance from the nail fold can help estimate the duration of symptoms (the growth rate is 1 mm/month in the toes and 3 mm/month in the fingers). Ultimate cause is unclear but may be associated with arterial spasm and ischemia.
  • Vitamin C deficiency (DiBaise M, 2019) (PJ, 2011) (Rollier R, 1955) (NIH, 2018) – First diagnosed by James Lind in sailors who were at sea for long periods of time in the 1700s, scurvy is associated with a deficiency in vitamin C, either due to diet (rare) or more commonly malabsorption, second-hand smoke exposure, and alcohol use disorder. Due to the importance of vitamin C for collagen production, the deficiency manifests as brittle nails, koilonychias, and splinter hemorrhages. Other than nail findings, classically patients will have gingival inflammation with corkscrew hairs and loose teeth.
  • Zinc deficiency (Pfeiffer C, 1974) (Morgan Z, 2011) – Can appear as white, opaque spots on the nail, more commonly in the index or fifth digits of the dominant hand. As mentioned above, these are also called Muehrcke lines, as they may be associated with low albumin levels.
  • Fat-soluble vitamin deficiency (al. S. M., 2011) – Deficiencies specifically in vitamins A, D, E, and K typically will cause nails to be softer, termed hapalonychia. Yellow discoloration of the nails, not to be confused with onychomycosis, can occur with vitamin E deficiencies. Warn patients that those fat-soluble vitamins can be toxic if taken in larger than recommended amounts, as these vitamins are stored in the liver and adipose tissue.
  • Water-soluble vitamin deficiency (Yiping M, 2014) (Cakmak SK, 2006) (Staggs CG, 2004) (Supplements., 2018) – The majority of water-soluble vitamins that, when deficient, present with abnormal nail findings, center around the B complex of vitamins. Koilonychia, as presented above, can occur with Vitamin B2 and B3 deficiency in particular. While these can be due to nutrient deficiencies from a diet lacking in dairy (think lactose intolerance), they can also occur from medications affecting their absorption (ie, nicotinamide or isoniazid therapy). Other than koilonychia, look for dermatologic manifestations of cheilitis, aphthous ulcers, and pharyngitis
  • Vitamin B3 deficiency, also known as pellagra, occurs with poor intake of poultry, nuts, seeds, legumes, and beef. Low levels can lead to a unique finding of half-and-half nail due to melanin deposition. Remember the 4 “D’s” of pellagra: dermatitis (hyperpigmented rash on sun-exposed regions), diarrhea, dementia, and death. Patients with this finding should be evaluated for renal failure, which commonly coexists. In general, it is rare to develop toxic levels of water-soluble vitamins, as those in excess are excreted in the urine. 
  • Finally, the most common deficiency to cause nail manifestations is biotin deficiency. While systemic signs of alopecia, myalgias, and paresthesias, brittle nails can develop through dietary lack of eggs, meat, fish, sunflower seeds, and peanuts. Other than nutrient deficiencies, they can be seen in patients who have malabsorptive diseases and alcohol use disorder.
Nail Conditions by Matrix Involvement (Richert, 2015)
Proximal Matrix

 

Longitudinal Ridging

Presents as shallow ridges, which can be physiologic (if multiple are noted) or associated with trauma (when a single ridge is present) and become more apparent as we age. When pathologic, associated with rheumatoid arthritis and peripheral vascular disease. (Michel C, 1997)

 

Longitudinal Grooves

Longitudinal Grooves – Also called Beau lines or transverse lines, present as depressions in part or the entirety of the nail affecting one or all of the nails. When multiple fissures are noted, termed onychorrhexis. Mucoid cysts may be present if a single smooth gutter is noted.

 

Pitting

Small depressions on the surface of the nail that vary in size and shape with no clear pattern of distribution. Most commonly present on the toenails, look for other dermatologic manifestations that may suggest underlying psoriasis (typically only seen with > 20 pits on nails), atopic dermatitisalopecia, or lichen planus.



Distal Matrix



Leukonychia

Nail will appear white due to abnormal keratinization of the nail matrix. May present in a half-and-half appearance that goes away with distal pressure. Myriad causes, some associated with trauma (preceded by subungual hematoma); if the lines are transverse (termed Mees’ lines), look for atypical causes such as arsenic poisoning, parasitic infections, and reactions to chemotherapy.



Erythronychia

Red discoloration of the nail matrix that disappears with pressure and is associated with systemic conditions such as psoriasislichen planus, and alopecia areata

 

Melanonychia

Melanin deposited in the nail plate showing up as bands. The color can vary.


 

  

What nail findings are seen with increasing age?

While many nail findings can be physiologic, due to deficiencies in either vitamins or minerals, or associated with systemic disorders, there are others that occur with increasing frequency simply due to progressing age. Examples include brittle nails, onychocryptosis, onychomycosis, and subungual hematomas.

 

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Brittle nail syndrome

  • As its name implies, patients will experience splitting of the nails on the free edge at the distal region of the nail. Oral biotin supplementation can be helpful. Have the patient avoid topical cosmetics and repetitive trauma, if possible.

 

 

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Onychocryptosis

May look similar to paronychia; look for inflammation of the lateral nail fold. Conservative treatment with partial removal of the affected nail portion is helpful. Preventive measures include teaching appropriate nail cutting technique and evaluating shoes to ensure they are not too small of a fit. (Martínez-Nova A, 2007)

 

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Onychauxis

Hypertrophy of the nail leading to shrinkage and discoloration. Can be painful and may be hard to distinguish from concurrent onychomycosis. Can be due to repetitive trauma from poor shoe compatibility and chronic toe contracture.

 

 

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Onychomycosis 

The most common nail infection of fungal origin, most often affecting the toenails, presenting with yellow patchy discoloration with nail thickening. Increased risk seen with older age and smoking; there has been genetic predisposition found. Treatment is targeted toward Trichophyton species, but other species such as Candida and Scopulariopsis have been reported. Treatment can be difficult and may require nail removal with systemic therapy (oral terbinafine). (Gupta AK, 2006) In the right population, consider testing for HIV. (Surjushe A, 2007)

  

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Subungual hematoma

Associated with trauma; look for a painful red discoloration under the nail that moves forward with time. Can be mistaken for melanoma; therefore, if there is no trauma history, consider referral for biopsy. If acute pain is noted, it responds well to pressure relief by drilling a hole (can use an 18-g needle) into the nail plate. Avoid damaging the nail matrix.

 

Conclusion

The above patient’s diagnosis was onychomycosis, likely secondary to her poorly controlled diabetes. She was placed on an oral prescription of terbinafine, and she was followed up with 2 months later with resolution of her symptoms. If the symptoms had not improved, then a podiatry consultation could be considered for toenail removal.

The nail is a gateway into the body and can help reveal underlying systemic conditions. It is important not to forget about nail evaluation when performing your general physical exam.

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References

Adhikari, S. S. (2018). Nail the Diagnosis. WILDERNESS & ENVIRONMENTAL MEDICINE .

al., C. e. (2015). Transverse Leukonychia with Normocalcemic Hyperparathyroidism. Proceedings of UCLA Healthcare.

al., S. M. (2011). A Case of Yellow Nail Syndrome with Dramatically Improved Nail Discoloration by Oral Clarithromycin. Case Rep Dermatol.

Cakmak SK, G. M. (2006). Half-and-half nail in a case of pellagra. Eur J Dermatol.

Chumley HS, D. J. (n.d.). Clubbing. In The Color Atlas and Synopsis of Family Medicine. New York, NY: McGraw-Hill.

DiBaise M, T. S. (2019). Hair, Nails, and Skin: Differentiating Cutaneous Manifestations of Micronutrient Deficiency. Nutrition in Clinical Practice.

Ghaffari S, P. L. (2018). Koilonychia in Iron-Deficiency Anemia. N Engl J Med.

Gupta AK, R. M. (2006). Diagnosing onychomycosis. Dermatol Clin, 365–9.

Hasunuma N, U. Y. (2014). True leukonychia in Crohn disease induced by selenium deficiency. JAMA Dermatol.

Jefferson J, R. P. (n.d.). Chapter 40: Nail Disorders . In Taylor and Kelly's Dermatology for Skin of Color, 2e. New York, NY: McGraw-Hill.

LeBlond RF, B. D. (n.d.). The Skin and Nails. In DeGowin’s Diagnostic Examination.

Lipner SR, S. R. (2016). Evaluation of nail lines: Color and shape hold clues. Cleveland Clinic Journal of Medicine.

Martínez-Nova A, S.-R. R.-P. (2007). A new onychocryptosis classification and treatment plan. J Am Podiatr Med Assoc.

Mayeaux, J. E. (n.d.). Normal Nail Variants. In S. M. Usatine RP, The Color Atlas and Synopsis of Family Medicine. New York, NY: McGraw-Hill.

Michel C, C. B. (1997). Nail abnormalities in rheumatoid arthritis. Br J Dermatol.

Morgan Z, W. H. (2011). Leukonychia on finger nails as a marker of calcium and/or zinc deficiency. Journal of Human Nutrition and Dietetics.

NIH. (2018). Vitamin C: Fact sheet for health professionals. Office of Dietary Supplements.

Pfeiffer C, J. E. (1974). Fingernail White Spots: Possible Zinc Deficiency. JAMA.

PJ, H. (2011). Who discovered how to prevent scurvy? The Pharmaceutical Journal.

Richert, B. C. (2015). Diagnosis Using Nail Matrix. . Dermatologic Clinics.

Rigopoulos D, L. G. (2008). Acute and chronic paronychia. . Am Fam Physician.

Rollier R, B. J. (1955). Degos' complex of vitamin C deficiency (depapillating glossitis with koilonychia). Bull Soc Fr Dermatol Syphiligr.

Scher RK, B. G. (n.d.). Chapter 15: Biology of Nails . In T. S. Kelly A, Taylor and Kelly's Dermatology for Skin of Color. McGraw-Hill.

Seshadri D, D. D. (2012). Nails in nutritional deficiencies. Indian J Dermatol Venereol Leprol .

Staggs CG, S. W. (2004). Determination of the biotin content of select foods using accurate and sensitive HPLC/avidin binding. J Food Compost Anal.

Supplements., N. O. (2018). Biotin: Fact sheet for health professionals. NIH.

Surjushe A, K. R. (2007). A clinical and mycological study of onychomycosis in HIV infection. Indian J Dermatol Venereol Leprol.

Tan AU, S. B. (2018). A review of diagnosis and treatment of acne in adult female patients. Int J Womens Dermatol, 56-71.

Tonelli M, W. N. (2015). Trace element supplementation in hemodialysis patients: a randomized controlled trial. BMC Nephrol.

Yiping M, Z. Z. (2014). Half-and-half nail in a case of isoniazid-induced pellagra. Postepy Dermatol Alergol.

 

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