NAILS

Anatomy1. Nail plate: is the hard and translucent

portion, composed of keratin

Its free edge is the part that

extends past the finger

2. Lunula : is the crescent

shaped whitish area of the nail bed

3. Eponychium or cuticle, is the fold of skin at the proximal end of the nail

4. Nail fold : a fold of hard skin overlapping the base and sides of the nail

5. Nail matrix : situated directly below the cuticle.  New cells form here to produce the nail plate.  It also contains blood vessels and nerves. If the matrix is

damaged the nail will grow deformed 6. Nail bed : It is continuation of the matrix and the part that the nail plate rests on

7. Hyponychium:

is the attach-

ment between

the skin of the

finger or toe

and the distal

end of the nail

Nail growth and factors affecting it• The nail can take between 5 - 6 months to

grow from the matrix to the free edge• In children the growth is rapid 6 – 8 weeks• In adults nails grow approximately by 1 mm

a week• Nail growth is quicker: ·  During pregnancy ·  In the summer than in the winter · On the hands than the feet • If the matrix is damaged by trauma, the nail

will grow back deformed

• Nail growth is inversely proportional to age• With advancing years the nail plate

becomes paler and opaque and white nails similar to those seen in cirrhosis, uraemia and hypoalbuminaemia may be seen in normal old persons

• Longitudinal ridging is present to some degree in most people after 50 years of age

I-Nail disorders

1.Congenital

2.Traumatic

3.Infectious

4.Neoplastic

1.Congenital

Anonychia

• Some or all the fingernails and toenails are absent without significant bone anomalies

• It is a rare condition

and may have an

autosomal dominant

inheritance pattern

Nail patella syndrome

• A rare autosomal dominant syndrome

• There is a tetrad of fingernail dysplasia with triangular lunula, absent or hypoplastic patellae, posterior

iliac horns,

deformation

of the radial

heads

Pachyonychia congenita• A rare autosomal dominant disease• There is hypertrophy of the nails

associated in some cases with nail bed and hyponychia hyperkeratosis

• May be associated with palmoplanter hyperkeratosis,

warty skin lesions on the limbs, hyperhidrosis and lustreless and kinky scalp hair

2.Traumatic

Acute trauma

• It is classified

with respect to

severity, ranging

from a small

hematoma to

digit amputation

Chronic repetitive traumaNail biting• It is found in 60% of children, 45% of adolescents and

10% of adults• The majority of moderate nail biters have no associated

psychiatric disorder• Patients are susceptible to bacterial and viral infections

producing whitlows. It may also result in the transportation of bacteria that are buried under the surface of the nail, or pinworms from anus region to mouth

• Regarding social effects the aesthetic aspect of the nail may affect employability, self-esteem, and interaction with other people

• The nails are typically short, with up to 50% of thenail bed exposed.

The free edge may

be even or ragged.

Surface change may

include splitting of the

nail into layers or a

sand-papered effect,

and the nail may acquire a

brown longitudinal streak

• Cure relies largely on the motivation of the patient

• Local antiseptics and antimicrobial ointments may help settle the infection secondary to nail-unit damage

• Antidepressants and behavioural therapy have been used with some success in limited studies

Hangnail• Trim the skin of the hangnail with a pair of clean

scissors. • These are due to hard pieces of epidermis breaking away from the lateral nail folds• Although often due to nail biting, they may result from many other minor injuries• The splits may be painful when they penetrate to

the underlying dermis• They should be removed with sharp, pointed

scissors

Trauma by footwear

• Due to repetitive trauma by

footwear,the great toenail

becomes thickened, yellow

and twisted (onycho-

gryphosis). It is most

commonly seen in

the elderly

• Treatment is either :

- Radical by surgical removal of the nail and matrix and is recommended in young persons with good circulation

- Palliative treatment requires regular paring and trimming of the affected nails, usually by a chiropodist

• Ingrowing toenail

• The lateral nail fold of the

great toe is penetrated

by the edge of the nail

plate, resulting in pain,

sepsis and, later, the

formation of

granulation tissue

• The main cause for the deformity is compression of the toe from the side due to ill-fitting footwear

• In infancy, ingrowing toenail most commonly occurs before shoes are worn, associated with crawling, or wearing undersized jumpsuits

• Treatment is by: -Avoiding tight-fitting or high-heeled shoes - oral antibiotics or topical antibiotic ointments

combined with local anaesthetic agents help to heal the toe faster and also provide pain relief

- Surgical removal of the ingrown toenail may be required if the condition worsens

3-Nail infections

• Paronychia

• It is a soft tissue infection around a fingernail

• It results from a breakdown of the protective barrier between the nail and the nail fold leading to entry of bacteria or fungi into the area

• It is the most common hand infection

Etiology

Acute paronychia• Usually results from a minor(e.g. nail biting)

trauma that breaks down the physical barrier between the nail bed and the nail allowing the infiltration of infectious organisms

• S. aureus is the most common infecting organism. Organisms, such as Streptococcus and Pseudomonas species, gram-negative bacteria, and anaerobic bacteria are other causative organisms

Chronic paronychia• It is primarily caused by a mixture of C.albicans

and bacteria • It can also be a complication of eczema• Most often it occurs in persons whose hands

are repeatedly exposed to moist environments or in those who have prolonged and repeated contact with irritants such as mild acids, mild alkalis, or other chemicals. People who are most susceptible include housekeepers, dishwashers, and swimmers

Clinically Acute paronychia• The presenting complaints are pain, tenderness, and swelling in one of the lateral folds of the nail• The affected area often appears erythematous and swollen• In more advanced cases, pus may collect under the skin of the lateral fold

• If untreated, the infection can extend into the eponychium, both lateral folds and in severe cases, the infection may track proximally under the skin of the finger and volarly to produce a felon (whitlow) which is an abscess involving the bulbous distal end of a finger

Chronic paronychia• Patients complain of symptoms lasting 6 weeks

or longer• The nail folds become swollen, erythematous,

and tender without fluctuance • Eventually, the nail plates become thickened

and discolored, with pronounced transverse ridges

• The cuticles and nail folds may separate from the nail plate, forming a space for the invasion of various microorganisms

Treatment Acute paronychia

• Oral antibiotics with gram-positive coverage against S aureus, such as amoxicillin and clavulanic acid (Augmentin) or clindamycin (Dalacine C), are usually administered concomitantly with warm water soaks 3-4 times/day

• Dalacine C and Augmentin also have anaerobic activity; therefore, they are useful in treating patients with paronychia due to oral anaerobes contracted through nail biting

• If the paronychia does not resolve or if it progresses to an abscess, it should be drained promptly

Chronic paronychia

• The avoidance of moist environments or skin irritants is essential for recovery

• Because of the 'mixed' etiology of the inflammation, many clinicians use antibiotic-anticandida-steroid creams combinations. Oral ketoconazole or fluconazole may be added in more severe cases

• Patients with diabetes and those who are immunocompromised need more aggressive treatment because the response to therapy is slower in these patients than in others

• Cryosurgery, using liquid nitrogen spray to the nail folds, or surgical removal of the proximal nail fold and adjacent part of the lateral nail folds, may cure recalcitrant cases

• Pseudomonas infection• It is always a complication of onycholysis or chronic

paronychia• The nail plate has a characteristic bluish-black or

green color due to accumulation of the pigment pyocyanin below the nail which may remain after

the organism has been removed• Treatment is as described for paronychia• Gentamicin or sulphacetamide eye drops can be

used to eradicate the colonization in resistant cases

4-Tumors

• Warts

• Fibrokeratoma:They

arise in the periunguium

and have a hyper-

keratotic tip and narrow base

• Subungual exostosis: It is a

benign bony outgrowth

of the distal part of the toe

Glomus tumour:

There is pain, which may be spontaneous or evoked by mild trauma or temperature change. Nail-plate changes depend on the location of the tumour. Matrix tumours cause splitting and distortion of the nail plate. Nail bed lesions are most likely to appear as bluish or red foci of 1-5mm diameter beneath the nail

• Squamous cell carcinoma: There are hype-rkeratotic, warty changes, erosions and fissuring, macerated cuticle,

periungual swelling, erythema

• Melanocytic nevi: Present as

longitudinal melanonychia

Malignant melanoma:There are many features that should suggest the possibility of malignant melanoma:

• The presence of brown-black

periungual pigmentation

• The pigmentation develops in

a single digit in adult life

• The pigmentation is evolving to become darker and broader and has blurred edges

• Longitudinal melanonychia(75% of cases)

Dermatoses affecting the nails

1-Psoriasis• Psoriasis is the most common disorder affecting fingernails (50% of psoriatics)• Pitting:Punctate surface depressions• Onycholysis:Separation of the nail from the nail bed either proximally or distally

• Subungual hyperkeratosis:

most marked distally and

extends proximally

• Splinter hemorrhage:may be

due to the increased capillary

prominence and

in nail-bed dermis

2-Darier's disease

• There are white and red

longitudinal lines and

distal notching

3-Lichen planus

• Nail involvement occurs in 10% of individuals with disseminated LP

• Nail apparatus involvement may be the only manifestation

• One, several, or all 20 nails may be involved ("twenty-nail syndrome," where there is loss of all 20 nails without any other evidence of lichen planus elsewhere on the body)

• There is thinning of the nail plate and longitudinal ridging

• Typically, the area of the

lunula is more elevated

than the more distal

portion

4-Alopecia areata

• The nail plate is rough

with a "hammered brass"

appearance

5-Eczema

• Severe pompholyx

around the nail folds

may cause nail

dystrophy, resulting

in irregular ridges

Nail signs in systemic disease

I-Abnormalities of shape1-Clubbing

• It is the bulbous uniform swelling of the soft tissue of the terminal

phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed• It is due to vasodilation of the digit blood

vessels, the cause of which is unknown

Causes : 1-Primary (idiopathic)clubbing e.g. familial clubbing 2-Secondary clubbing include the following:• Pulmonary disease e.g. Lung cancer, cystic fibrosis• Cardiac disease e.g. Cyanotic congenital heart disease• GIT disease e.g. inflammatory bowel disease• Skin disease e.g. Pachydermoperiostosis• Malignancies e.g. Thyroid cancer, Hodgkin disease,

leukemia• Miscellaneous conditions e.g. Acromegaly, pregnancy,

and hypoxemia possibly related to long-term smoking of cannabis

2-Koilonychia

• Nails become concave (spoon-shaped)

• It is common in infancy as a benign feature of the great toenail

• The most common

systemic association

is with iron deficiency

Beau's lines• They are deep grooved lines that run from side to side on the fingernail due to a tempo- rary cessation of cell division in the nail matrix• This may be caused by an infection or trauma in the nail matrix

Beau's lines

Any severe systemic illness that disrupts nail growth, Raynaud's disease, pemphigus, trauma

Beau's lines

Any severe systemic illness that disrupts nail growth, Raynaud's disease, pemphigus, trauma

Beau's lines

Any severe systemic illness that disrupts nail growth, Raynaud's disease, pemphigus, trauma

II-Changes in nail surface

• Systemic reasons include: coronary occlusion, hypocalcaemia, diabetes, certain drugs - including beta blockers

Muehrcke's lines:

• They are superficial (not grooved as beau’s line) white lines that extend all the way across the nail and lie parallel to the lunula

• The lines are actually in the

vascular nail bed

underneath the nail plate,

and so they do not move

with nail growth and

disappear when pressure

is placed over the nail

• The appearance of Meuhrcke's lines is nonspecific, but they are often associated with decreased protein synthesis, which may occur during periods of metabolic stress (e.g., after chemotherapy) and in hypoalbuminemic states such as the nephrotic syndrome

• 'True' Leukonychia• It is the most common form of leukonychia, small white spots

affecting one or two nails• Picking and biting of the nails are a prominent cause in young

children and nail biters• In most cases, they disappear after around eight months, which is the amount of time necessary for nails to regrow completely

III-Changes in nail color

Terry’s nails

• The nails are white proximally and normal distally

• It occurs in cirrhosis,

congestive heart

failure and adult-

onset diabetes

• Yellow nail syndrome• The nails are yellow due to

thickening, sometimes with

a tinge of green• The lunula is obscured and

there is increased transverse

and longitudinal curvature

and loss of cuticle• It is usually accompanied by

lymphoedema and pleural

effusions

Color changes due to drugs

• Chloroquine may produce blue-

black pigmentation of the nail

• Arsenic may produce

longitudinal bands of pigment

or transverse white stripes (Mees' stripes) across the nail

Nail cosmetics

• Professional taking care of the fingernails is known as a manicure

• Professional taking care of the toenails is known as a pedicure

•

Nail polish

• In 1930, Charles Revson developed the first pigmented, opaque nail polish, which launched Revlon

• Nail polish basically consists of pigments suspended in a volatile solvent to which film formers have been added. The ingredients are as follows:

• 1-Cellulose film formers, such as nitrocellulose. These give gloss, body and gel structure

• 2-Resins, such as toluene sulphonamide formaldehyde resin, to improve the gloss and adhesion of the film

• Plasticizers, such as dibutylphthalate, added to give the film pliability, to minimize shrinkage, and soften and plasticize the cellulose

• 4-Suspending agents, such as bentonite, for non-settling and flow. They keep pigments in suspension on shaking

• 5-Solvents (such as butyl) and diluents (such as toluene), which keep other ingredients in a liquid state and control the application and drying time

• 6-Color substances. These are either inorganic (iron oxides) or a variety of certified organic colors (D and C yellow, A1 lakes). In principle, they require to be insoluble in a nail lacquer system

Problems of nail polish

1-Contact dermatitis• Frequently appears on any part of the

body accessible to the nails, with no signs in or around the nail

The commonest areas involved are the eyelids, the lower half of the face, the sides of the neck and the upper chest• Formaldehyde resin is the most common cause

• 2-Nail plate discoloration:• Nail-plate staining from the use of polish is

most commonly yellow-orange in color• 3-Nail polish removers:• These are composed of various solvents

such as acetone which occasionally cause trouble by excessive drying of the nail plate and may be responsible for some inflammation of nail folds