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Half and half nail syndrome - Nail and Distal Digit
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Half and half nail syndrome - Nail and Distal Digit

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Contributors: Shari Lipner MD, PhD, Susan Burgin MD, Bertrand Richert MD, Robert Baran MD
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Synopsis

Half-and-half nails, also known as Lindsay's nails, was first described in 1967 and is one of the most characteristic (but not pathognomonic) onychopathies seen in chronic renal failure. Although the exact pathogenesis is unclear, it is speculated that acidosis and an increase in toxic uremic substances occurring subsequent to sudden renal decompensation may stimulate melanin formation by nail matrix melanocytes.

Half-and-half nails are seen in an estimated 20%-50% of chronic renal failure patients. It is also seen in up to 84% of patients with azotemia and 8%-13% of hemodialysis patients; there is some debate whether the frequency of these changes correlates with duration of dialysis. Other reported causes include Kawasaki disease, hepatic cirrhosis, pellagra, zinc deficiency, chemotherapy, Behçet disease, and Crohn disease. Half-and-half nails have also been reported in patients without any systemic abnormality.

Fingernails are affected more often than toenails. Clinically, nails have a proximal pale pink or dull white "ground glass appearance" that is sharply demarcated from a red, pink, or brown distal portion. The transverse distal bands occupy 20%-60% of the total nail length.

There is no correlation between the distal band length and severity of renal failure. Furthermore, the half-and-half nail pattern is persistent, as there is no tendency of the bands to move with nail growth. Nonetheless, this phenomenon may reverse itself after successful renal transplantation, but not with hemodialysis or changes in hemoglobin or albumin levels.

Codes

ICD10CM:
L60.8 – Other nail disorders

SNOMEDCT:
50077007 – Half-and-half nail

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Nail changes frequently seen in kidney disease include half-and-half nails, absence of lunula, splinter hemorrhages, and brittle nails. See nail changes of chronic renal failure.
  • Absence of lunula – may be associated with chronic renal failure, trauma to the terminal digit, multiple myeloma, scleroderma, hyperparathyroidism, and bone tumors, or may be seen in otherwise healthy individuals
  • Splinter hemorrhages – associated with renal disease, systemic lupus erythematosus, rheumatoid arthritis, mixed connective tissue disease, vasculitic syndromes, bacterial endocarditis, and trauma
  • Muehrcke lines – double white transverse bands in nail beds that regress and disappear when serum albumin normalizes; associated with nephrotic syndrome (hypoalbuminemia)
  • Mees' lines – single white transverse band in nail plates; associated with acute renal failure, arsenic poisoning, septicemia, aortic dissection, sickle cell anemia in crisis, and heavy metal poisoning
  • Beau lines – transverse depressions in nail plates; due to acute or chronic stress or systemic illness; examples include paronychia, local trauma, medications, myocardial infarction, pemphigus, and rheumatic fever
  • Koilonychia – spoon-shaped nails; associated with chronic anemia
Other nail changes associated with systemic diseases:
  • Terry nails – proximal three-fourths of nail is pale and wide, distal one-fourth (1-to 2-mm band) is narrow and deep red; associated with hepatic cirrhosis; may be seen in peripheral vascular disease, Raynaud phenomenon, connective tissue diseases, or in otherwise healthy individuals
  • Nail pitting – seen in psoriasis, alopecia, eczema, neurotrophic conditions, Reiter syndrome
  • Clubbing – seen in cyanotic congenital heart disease, inflammatory bowel disease, biliary cirrhosis, cystic fibrosis, esophageal cancer; can be familial and not associated with systemic disease
  • Onycholysis – distal nail pulled away from nail bed; associated with hyperthyroidism (Plummer nails), hypothyroidism, fungal infection, psoriasis, or secondary to trauma

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Reviewed: 06/25/2018
Last Updated: 07/13/2018
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Half and half nail syndrome - Nail and Distal Digit
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Half and half nail syndrome : Creatinine elevated, Half-and-half nail
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