Visualdx.com no longer supports your web browser (Internet Explorer version 9 or lower). See what browsers we support.
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.
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.
Can manifest with nail pitting, leukonychia, and an oil drop sign on the nail bed. Look for cutaneous psoriasis as a coexisting feature.
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)
Classically associated with subacute bacterial endocarditis; they can be seen with vitamin C deficiency as well.
Classically associated with severe pulmonary disease (COPD, lung 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)
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)
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)
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:
When it comes to the specific complaint, it is important to know the following information:
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.
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.
Vitamin and mineral deficiencies
Nail Conditions by Matrix Involvement (Richert, 2015)
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 – 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.
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 dermatitis, alopecia, or lichen planus.
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.
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.
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)
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.
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)
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.
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.
Become a VisualDx subscriber today and gain access to clinical information and medical images of these nail conditions and for thousands of other diagnoses. Your first 30 days are FREE.
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.
VisualDx is an award-winning diagnostic clinical decision support system that has become the standard electronic resource at more than half of U.S. medical schools and more than 1,500 hospitals and institutions nationwide. VisualDx combines clinical search with the world's best medical image library, plus medical knowledge from experts to help with diagnosis, treatment, self-education, and patient communication. Expanding to provide diagnostic decision support across General Medicine, the new VisualDx brings increased speed and accuracy to the art of diagnosis. Learn more at www.visualdx.com.