a brief review of nail diseases by, dr. mohammad baghaei

2017

FACEDOUX Dr.Mohammad Baghaei

FINGERNAIL AND TOENAIL ABNORMALITIES The nail organ is an integral component of the digital tip. It is a highly versatile tool that protects the fingertip, contributes to tactile sensation by acting as a counterforce to the fingertip pad, and aids in peripheral thermoregulation via glomus bodies in the nail bed and matrix. Because of its form and functionality, abnormalities of the nail unit result in functional and cosmetic issues

A brief review of Nail Disease by, Dr. Mohammad Baghaei, Cosmetic Scientist

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Fingernail and Toenail Abnormalities


The nail organ is an integral component of the digital tip. It is a highly versatile tool that protects the fingertip, contributes to tactile sensation by acting as a counterforce to the fingertip pad, and aids in peripheral thermoregulation via glomus bodies in the nail bed and matrix. Because of its form and functionality, abnormalities of the nail unit result in functional and cosmetic issues. The structures that define and produce the nail (nail plate) include the matrix (sterile and germinal), the proximal nail fold, the eponychium, the paronychium, and the hyponychium . Collectively, the nail bed (sterile matrix), nail fold, eponychium, paronychium, and hyponychium are referred to as the perionychium.


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Nail Growth

Development of the nail matrix begins in the ninth embryonic week from the nail anlagen. By week 16, the fetal nail is identifiable. Nearly 90% of the nail plate is produced by the proximal half of the matrix, more specifically, the germinal matrix. As a result, more of the nail plate substance is produced proximally, leading to a natural convex curvature of the nail from proximal to distal. Ulnar and radial projections of the matrix extend proximally to form points or horns of the matrix. These lateral horns are attached to the dorsal expansion of the lateral ligament of the distal interphalangeal joint (DIP).

Nail growth is separated into 3 areas: (1) germinal matrix, (2) sterile matrix, and (3) dorsal roof of the nail fold. The germinal matrix has the following characteristics: It is found on the ventral floor of the nail fold; The nail is

produced by gradient parakeratosis


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Cells near the periosteum of the phalanx duplicate and enlarge (macrocytosis)

Newly formed cells migrate distally and dorsally in a column toward the nail

Cells meet resistance at established nail, causing them to flatten and elongate as they are incorporated into the nail

It initially retains nuclei (lunula); more distal cells become nonviable and lose nuclei

The sterile matrix has the following characteristics: The area is distal to the lunula It has a variable amount of nail growth. It contributes squamous cells, aiding in nail strength and

thickness It has a role in nail plate adherence by linear ridges in the sterile

matrix epithelium The dorsal roof of the nail fold has the following characteristics: The nail is produced in a similar manner as the germinal matrix The cells lose nuclei more rapidly It imparts shine to the nail plate

Nail growth is estimated at 3-4 mm per month. Complete nail plate growth takes approximately 6 months. Certain factors increase the rate of the growth. These include longer digits, summer months, young persons (< 30 y), and nail biters.


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Fingernail and Toenail Abnormalities


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Hamman-Rich syndrome (acute interstitial pneumonitis)

Nail clubbing has been associated with various underlying pulmonary

and cardiovascular disorders, as well as with neoplastic, infectious,

hepatobiliary, mediastinal, endocrine, and gastrointestinal diseases.

Nail clubbing occurs when the angle made by the proximal nail fold

and the nail plate, termed the Lovibond angle, is greater than 180°

(shown).Hamman-Rich syndrome, or acute interstitial pneumonitis, is

a form of idiopathic interstitial pneumonia that is characterized by

inflammation of the lung interstitium. With advanced interstitial lung

diseases, digital clubbing and signs of right heart failure may appear.


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Fungal infections of the fingernails and toenails (onychomycosis)

Fungal infections of the fingernails and toenails (onychomycosis) . Onychomycosis is a common fungal infection of the nail that is most frequently caused by a dermatophyte. Onychomycosis is most prevalent in the toenails of adults and is more commonly found in patients with certain comorbid diseases such as diabetes, tinea pedis, and psoriasis. Management of onychomycosis includes a multispecialty team of healthcare providers. Early treatment of this infection, and new topical therapies are providing expanded options so clinicians can individualize treatment for this difficult to manage condition.


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Lunula

The lunula (shown) is most noticeable on the thumb, although the eponychium may partially or completely cover the lunula. Absence of the lunula (anolunula) of the thumb should prompt investigation for anemia or malnutrition. However, this may also be a normal finding. Anolunula of other digits is nonspecific.

Absence of the lunula may indicate the need to perform a complete

blood count.

The lunula is the distal extent of the germinal matrix of the nail bed. Abnormalities of the lunula are common and may lead clinicians down varied diagnostic paths. A pyramidal lunula may be a sign of excessive manicure or trauma. A pale blue lunula may indicate diabetes mellitus, whereas a red discoloration of the lunula may signify cardiovascular disease, collagen vascular disease, hematologic malignancy, or another serious diagnosis. The nail shown is lacking the lunula.


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Yellow nail syndrome

Yellow nail syndrome is an extremely rare disorder characterized by malformations affecting the fingernails and toenails, abnormalities affecting the lungs and the airways (respiratory tract), and swelling or puffiness in different parts of the body because of the accumulation of protein-rich fluid (lymph) in the soft layers of tissue under the skin (lymphedema). Yellow nail syndrome usually affects older adults. The exact cause of yellow nail syndrome is not known. Occasionally, yellow nail syndrome has been reported to run in families suggesting that genetic factors may play a role in the development of the disorder in these cases. The treatment of yellow nail syndrome is geared toward the symptoms present in each individual.

Treatment may include antibiotic therapy for repeated respiratory infections. The yellowed, malformed nails may improve without therapy. In some cases, the changes may be permanent. Vitamin E has been used to treat nail changes. Corticosteroids have also been used to treat individuals with yellow nail syndrome. Surgical management of respiratory problems such as pleural effusions has been used in some cases.

Genetic counseling may be of benefit for affected individuals and their

families. Other treatment is symptomatic and supportive.


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Koilonychia

Koilonychia is an abnormality of the nails that is also called spoon-shaped (concave) nails It is primarily recognized as a manifestation of chronic iron deficiency, which may result from a variety of causes, such as malnutrition; gastrointestinal blood loss; worms; gastrointestinal malignancy; and celiac disease diabetes mellitus, protein deficiency (especially in sulfur-containing amino acids), and Raynaud disease, as in the present case. Other causes of koilonychia are high altitude, trauma, and exposure to petroleum products, and it can even be hereditary. Therefore, spoon-shaped nails should prompt an evaluation for possible iron deficiency and the underlying cause.


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half nails -and-Lindsay half

half nails refers to a condition in which the proximal -and-The term Lindsay half

80%) of the nail bed is white and the distal portion is dark (red, -portion (40

edema and anemia. These nails pink, or brown). The white portion is related to

are indicative of renal disease. Terry nails refer to nail beds in which the

proximal 80% of the nail bed is white and the distal portion is a normal pink

nail bed.); the condition is caused by a decreased vascular supply to the shown(

Terry nails are indicative of hepatic disease, although they can also suggest

.diabetes mellitus, congestive heart failure, hyperthyroidism, and aging

half nails, were described in 1967 as red, pink, or -and-Lindsay’s nails, or half

cupying 20 to 60% of the nail bed in patients with chronic brown bands oc

kidney disease. There is no correlation between the degree of azotemia and

the percentage of nail bed that is occupied. The proximal white band is

n band from increased thought to result from chronic anemia and the brow

-melanin deposition distally, possibly from an increased concentration of β

stimulating hormone. There is no specific therapy beyond the –melanocyte

.treatment of the underlying chronic kidney disease


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Proximal (white) subungual onychomycosis

Proximal subungual onychomycosis (PSO) is a rare fungal nail

infection that is associated with immunodeficiency or local trauma.

The white patch initially appears under the nail fold, but it

progressively migrates distally with nail growth. If PSO is caused by a

mold, marked periungual inflammation is usually present. PSO

requires systemic antifungal treatment when the lunula is involved;

topical agents may be sufficient when only the distal nail is affected.

In contrast, onycholysis (shown) is the distal separation of the nail

plate from the underlying nail bed, usually no inflammation is

involved. It is associated with conditions such as thyrotoxicosis,

psoriasis, eczema, trauma, contact dermatitis, tetracycline, toxic

exposures (solvents), blistering from autoimmune disease, and

porphyria cutanea tarda (onycholysis and skin blistering from sun

exposure). Therapy is dependent on the etiology and includes

removing the predisposing cause, keeping the nails short, and

avoiding exposure to contact irritants and moisture.


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Longitudinal brown lines

Longitudinal brown lines (arrows) form as a result of increased melanin production by nail matrix melanocytes.These lines are associated with Addison disease, a melanocytic nevus at the nail base, breast cancer, melanoma (check for periungual pigmentation), and trauma. Longitudinal Linear Lesions

Longitudinal pigmented bands are normal findings in the nails of dark-skinned persons, occurring in more than 77 percent of blacks older than 20 years. These findings present a diagnostic problem because they must be differentiated from subungual melanomas, which also occur in older age groups and constitute 50 percent of melanomas in dark-skinned populations.


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Beau lines

Beau lines (arrow) are transverse depressions in the nail plate resulting from temporary cessation of nail growth. Causes include intermittent doses of immunosuppressive therapy or chemotherapy, nail injury, cold temperatures, and illness. Severe zinc deficiency has also been proposed as a cause of Beau lines. By noting the location of a Beau line on the nail, a clinician can determine the approximate date of the illness associated with it. Moreover, the depth of the line provides a clue to the severity of the illness.


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Onychorrhexis Onychorrhexis, or the presence of longitudinal striations or ridges on the nail plate, can simply be a sign of advanced age, but it may also be associated with conditions such as rheumatoid arthritis, peripheral vascular disease, lichen planus, and Darier disease (broad white and red striations in the nails). A central vertical ridge or groove may be due to myxoid cysts (shown) that appear near the nail fold; myxoid cysts are associated with osteoarthritis.


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Splinter hemorrhages

Splinter hemorrhages are caused by small areas of bleeding of the distal capillary loops in the nail bed and are most commonly associated with subacute bacterial endocarditis (classic finding) and local trauma.

These red or brown linear hemorrhages (shown) may also be associated with vasculitis, micro emboli, trichinosis, onychomycosis , psoriasis, SLE, pityriasis rubra pilaris, or renal failure.


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Pitting Small punctate depressions of the nails, or "pitting" (shown), is caused by proximal nail matrix inflammation. Nail pitting is caused by defective development of the layers of the superficial nail plate. It is common in patients with psoriasis and can affect up to 50% of people suffering from this condition. Nail pitting can also be associated with other conditions, including connective tissue disorders, alopecia areata, and sarcoidosis. Any condition that can cause a superficial and localized inflammation of the skin (dermatitis) can also affect the nails and result in nail pitting. Nail pitting can be associated with other abnormalities of the nails, including nail separation, flaking or crumbling, or other damage to or changes in the nail. Nail pitting that is associated with disease processes generally shows involvement of multiple or all nails, while trauma to an individual nail bed can cause localized pitting or disruptions in a single nail.


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Tuberous sclerosis

Tuberous sclerosis complex is a genetic disorder that causes benign tumors to grow in many different organs. Ungual or periungual fibromas may appear in adolescents or adults with tuberous sclerosis. Fibromas may cause distortion of the nail or nail bed. They can occur as an isolated sign of tuberous sclerosis. Generally, when these fibromas involve the toes, they may bleed and cause discomfort.

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Facedoux


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a brief review of nail diseases by, dr. mohammad baghaei

Education