Onycholysis - Nail and Distal Digit
Alerts and Notices
Synopsis
Fingernail onycholysis is more common in women than men and is common in patients with hand dermatitis. Fingernail and toenail onycholysis is most often caused by trauma. Other causes of onycholysis include hyper- and hypothyroidism, pregnancy, porphyria, pellagra, syphilis, atopic dermatitis, psoriasis, irritant or allergic contact dermatitis, lichen planus, congenital abnormalities of the nails, onychomycosis and other infections, and underlying malignancies. Tetracycline, quinolones, oral contraceptives, and certain chemotherapeutic agents are the most frequently associated medications. Systemic retinoids may also be culprits.
Blistering diseases, such as porphyria cutanea tarda or pseudoporphyria, will give rise to pain followed by onycholysis when a subungual vesicle or bulla appears. This is induced by sunlight and is known as photoonycholysis.
In children, onycholysis is most often due to trauma particularly when one or a few nails are affected. Psoriasis, lichen planus, and congenital abnormalities are also possibilities. If these etiologies have been ruled out, a systemic cause should be explored.
Codes
ICD10CM:L60.1 – Onycholysis
SNOMEDCT:
75789001 – Onycholysis
Look For
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Yellow nail syndrome – Look for yellow nails, increased transverse curvature.
- Psoriasis – Look for pitting, splinter hemorrhages, salmon patches of the nails, and erythematous scaly plaques on the skin. Onycholysis may be seen in psoriasis.
- Onychomycosis – Thickened, discolored nails with subungual hyperkeratosis. Onycholysis may be seen in onychomycosis.
- Lichen planus – Longitudinal ridging, pterygium formation, and splinter hemorrhages. Onycholysis may be seen in lichen planus.
- Allergic contact dermatitis
- Medication use, porphyria cutanea tarda, pseudoporphyria – See photoonycholysis.
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.Subscription Required
References
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Last Reviewed:06/04/2018
Last Updated:06/04/2018
Last Updated:06/04/2018
Patient Information for Onycholysis - Nail and Distal Digit
Overview
Nail lifting (onycholysis) is the spontaneous separation (detachment) of the fingernail or toenail from the nail bed at the end of the nail (distal) and/or on the sides of the nail (lateral). The appearance of nail lifting may resemble a half-moon, or the free edge of the nail may rise up like a hood. Nail lifting creates space under the nail that gathers dirt and debris made of protein in the nails (keratin). As water accumulates under the nail, bacteria and yeast can also cause the area to become infected.Nail lifting may occur with other skin conditions, such as various forms of eczema (including hand dermatitis), psoriasis, and lichen planus. Nail lifting may also occur with underlying medical problems, including thyroid disease, pregnancy, some forms of infection, and rarely some forms of cancer. Other possible causes are injury to the nails, use of nail cosmetics, and aggressive manicures.
Nail lifting may be caused by some medications, such as chemotherapy and drugs made from vitamin A. Some medications (commonly tetracycline) may interact with sunlight to cause nail lifting.
Who’s At Risk
Nail lifting may affect people of all ages. Women are affected more frequently than men.Signs & Symptoms
Nail lifting occurs on the fingernails and the toenails. The nail separates from the end (distal) and/or the sides (lateral) of the nail bed and may even separate completely from the finger.Self-Care Guidelines
- Thoroughly clip away as much of the detached nail as possible, repeating this at weekly intervals.
- Gently brush the nail and surrounding tissue with plain soap and water once daily, rinsing carefully, and then drying the area with a hair dryer.
- Protect the nails by wearing plastic gloves worn over light cotton gloves to avoid frequent contact with water. Use any mild cleanser as an alternative to water and soap.
When to Seek Medical Care
See your doctor if the nail lifting becomes bothersome. Your doctor may perform tests for conditions or infection that may be causing the nail lifting.Treatments
In addition to the self-care measures noted above, your doctor may prescribe:- Treatment for any skin conditions, medical problems, or exposures that may be causing your nail lifting.
- If bacterial or fungal infection is present, you may require antibacterial or antifungal treatment.
References
Bolognia, Jean L., ed. Dermatology, pp.1062, 1064. New York: Mosby, 2003.
Freedberg, Irwin M., ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. pp.2001, 2003. New York: McGraw-Hill, 2003.
Onycholysis - Nail and Distal Digit