Applied aspects of nail
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Transcript of Applied aspects of nail
ALTERATIONS IN THE NAIL PLATE
DR. YUGANDAR
KOILONYCHIA
Reverse curvature in longitudinal & Transverse axes giving a concave dorsal aspects of nail
Signs most prominent in great toe & thumb
Iron def anemia in adults Common feature in infancy great toe
nail,persistence indicative of deficiency of cysteine rich keratin in Trichothiodystrophy
KOILONYCHIA
-Spoon shaped deformity
-Normal Convexity replaced byCentral Concavity
-Surrounded by Distal & Lateral Margins
-Lichenplanus,hypothyroidism,hemochromatosis,20- nail dystrophy
KOILONYCHIA(SPOON NAIL)
BEAUS LINES
Single horizontal ridge by horizontal lines of darkened cells and linear depressions
It is the result of any interruption in the protein formation of the nail plate
trauma, illness, malnutrition or any major metabolic condition, chemotherapy
BEAU’S LINES
Multiple transverse ridging
Chemotheraphy with Breast Cancer
Beau’s line; Zinc deficiency
BEAU’S LINES
TRACHYONYCHIA (20-NAIL DYSTROPHY,SANDPAPERED NAILS)
Rough surface affecting all nail plates,idiopathic forms k/s 20 nail dystrophy
k/a Sand Blasted Nails in French means grey,roughened surface
Alopecia areata, Psoriasis,Lichen planus
Histology shows spongiosis & lymphocytic infiltrate
ONYCHOMADESIS(NAIL SHEDDING) Detachment of the
nail plate from proximal nail fold,d/t severe insult that produces arrest of nail matrix activity
Proximal detachment of nail
Most often traumatic
ONYCHAUXIS
GREAT TOE NAILS GROSSLY THICKENED WITH TRANSVERSE RIDGING ( ONYCHAUXIS )
Nail thickening d/t subungual scales
Subungual hyperkeratosis
psoriasis,onychomycosis,eczema
ONYCHIA
• Inflammation of the nail matrix
• It is accompanied by pus formation
• There is Inflammation within the nail plate
ONYCHOCRYPTOSIS (INGROWN TOE NAIL) Lateral ingrowing usually affects hallux,
great toe Teenagers,Young adults,congenital
malalignment of big toes nails often present
Ppt by improper nail cutting and hyperhidrosis
Growth of granulation tissue undergoes epithelialization
DD: Multiple Periungual Pyogenic granulomas d/t retinoids,ART drugs
ONYCHOCRYPTOSIS :TREATMENT
Prevention through patient education Removal of embeded spicule Uplifting of lateral nail plate Chemical – 80% Phenol,Laser or
Surgical removal of Lateral Matrix in severe cases
Granulation tissue prevented by topical antibiotics & steroids,
ONYCHOCRYPTOSIS(INGROWN NAILS)
Also known as ingrown nails
May affect either the fingers or toes
The nail grows into the sides of the flesh & may cause infection
WASHBOARD NAILS
HABIT TIC DEFORMITY
Dystrophic nails Transverse ridging Absent of cuticle Excoriation of
Proximal nail fold
ONYCHORRHEXIS
Brittle nails,split vertically, peel or have
vertical ridges.
The result of heredity, the use of strong
solvents in the workplace or the home,
including household cleaning solutions.
Lichen Planus,tumours which
compromise vascular supply
ONYCHORRHEXIS
Thinning of Nail plate
Longitudinal ridging & fissuring
Mild Longitudinal ridging is characteristic of Ageing
ONYCHOGRYPOSIS
Claw-type nails that are characterized by a thickened nail plate
Often the result of trauma
This type of nail plate will curve inward, pinching the nail bed and sometimes require surgical intervention to relieve the pain.
ONYCHATROPHIA
It is an atrophy or wasting away of the nail plate
which causes it to lose its luster, become smaller & sometimes shed entirely
Injury or disease may account for this irregularity
PINCER NAILS
Painful abnormality of nails Toe >> finger nails a/w subungual exostosis Distal nail plate over curved &
compresses subungual tissue
BRITTLE NAILS a vertical splitting or
separation of the nail plate layers at the distal (free) edge of the nail plate
characteristic of the natural aging process.
overexposure to water and chemical solvents such as household cleaning solutions
Brittle nail
PACHYONYCHIA CONGENITA
AD,very rare Hypertrophy of nails occurs a/w nail bed
hyperkeratosis PC 1: Normal by birth,Progressively
discoloured,thicken more on hands,Palmo-plantar hyperkeratosis & warty lesions at knee,elbows,buttocks,Defect Keratins 6a & 16
PC 2: Less severe nail thickening & Keratosis, a/w hamartomas,Kinky scalp hair,epidermal cysts,Defect keratins 6b & 17
PACHYONYCHIA CONGENITA
ALTERATIONS IN NAIL SIZE
ANONYCHIAABSENCE OF ALL OR PART OF ONE OR SEVERAL NAILS
Congenital:Mutation in R-
Spondin 4 gene
Transient :Due to nail shedding
Acquired:Due to scarring of nail
matrixTrauma,Burns,Surgery,Lichenplanus.Epidermolysis bullosa-
irreversible nail loss
ANONYCHIA
It is a/w DOOR syndrome,AEC syndrome,EEC syndrome,TOOD syndrome
Anonychia atrophica : it is an acquired nail dystrophy,Permanent,secondary to nail matrix damage
ANONYCHIA
Congenital absence of nails in child
MICRONYCHIA
Nails Smaller Uni or Bilateral Identifies in Iso- Kikuchi
syndrome,Zimmerman-Laband syndrome,Turners syndrome
MACRONYCHIA
Naila are larger Uni Or Bilateral It is a/w Macrodactyly as in
Vonrecklinnghausens disease,Maffucci syndrome,Klippel-Trenaunay-Weber syndrome
POLYNYCHIA
Existence of two or more separate nails on one digit
Rare Congenital anomaly Lawrence-Moon-Biedl syndrome
POLYNYCHIA
RACKET NAILS AD Girls > Boys Thumbs >> Other fingers Epiphyses of terminal phalanx of
thumb closes prematurely by age of 7-10yrs,normally at 13-14 yrs
Distal phalanx of affected thumb is shorter & wider than normal
Affected nails are opaque,short with loss of normal curvature
Acquired: cong syphilis,acro osteolysis
RACKET NAILS
NAIL PATELLA SYNDROME
AD Nails partially or totally absent Linkage b/w locus controlling disorder &
ABO blood group LMX1B gene plays imp role,located on
long arm of ch 9 Tetrad constitutes Nail
dystrophy,Hypoplastic or absent patellae,Elbow dysplasia,Iliac horns
Thumb >> other finger Affected nails 1/3 or 1/2 of normal size
NAIL PATELLA SYNDROME
Lunula are triangular or V shaped Bilateral Post Iliac horns on x-ray
Pathognomonic Prenatal diagnosis by USG Possible Other features Lester iris,Open angle
glaucome,Palmoplantar hyperhidrosis, Scapular hypoplasia
NAIL PATELLA SYNDROME
Traingular Lunula
ISO KIKUCHI SYNDROME
Nails of index finger small or absent Unilateral or bilateral Miconychia is MC presentation Terminal bifurcation of distal phalanx is
characteristic feature
DOLICHONYCHIA
Nails appear narrow & long Normally ratio b/w length & breadth of
nail is 1 + 0.1 In these condition about 1.9 Identified in Ehlers danlos
syndrome,Marfans syndrome
CIRCUMFERENTIAL NAILS
Nails are Tubular Congenital seen in siblings Nails may cover all sides of one or
more fingers
CONGENITAL MALALIGNMENT OF BIGTOE
Lateral deviation of long axis of nail growth relative to distal phalanx one big toe or both
Medial deviation is rare Nails discoloured & thickened,often
traingular in shape MC identified in Monozygotic &
Dizygotic twins Nail grows temporarily fast than bone
of hallux,Realignment occurs when bone growth catches up with nail post natally
PERIODIC SHEDDING
Nails of great toe MC affected AD One or more nails shed repeatedly Regrowth of nail incomplete,defective Trauma from ill fitting shoes is MC
cause of repeated shedding of nails in sports persons
ALTERATIONS IN NAIL SHAPE
CLUBBING
Increased Transverse & Longitudinal nail curvature with hypertrophy of soft tissue components of digital pulp
Hyperplasia of fibrovascular tissue at base of nail gives Rocked nail appearance
Lovibonds angle, Curths angle, Schamroth’s window
Also K/A Hippocratic nails ,Watch glass nails
CLUBBING
Patient with cystic fibrosis
CLUBBING
Increased blood flow through vasodilated plexus of nail unit vasculature > Vessel hyperplasia
Altered Vagal tone Microvascular infarcts PDGF may responsible for vascular changes Painful clubbing indicative of periostitis
associated with HPOA,characteristic of thoracic malignancy
Pachydermoperiostosis : idiopathic,Puberty,a/w spade like thickening of foot & hands
CLUBBING
SHELL NAILS RACKET NAILS
Similar to clubbed nails Girls with bronchiectasis
around 5 yrs age Avulsion of nail plate
reveals atrophy of nail bed instead of hypertrophy noted in true clubbing
Broad & Shortened nails usually seen thumb & great toes
Similar to clubbed nails D/T stubby appearance
Arrest in distal phalangeal formation
CLUBBING
Lovibond angle : angle at junction of nail plate & proximal nail fold
Normally less than 160 degrees
Clubbing angle is more than 180 degrees
CLUBBING
Curth’s angle : Angle at Distal interphalangeal joint
Normally 180 degrees
Clubbing diminished less than 160 degrees
RACKET NAIL WITH CLUBBING RACKET NAILS
DISEASES OF NAIL BED
PSORIASIS
Multiple nail pits on dorsal nail plate
Oil staining of nail bed
Distal Onycholysis
PSORIASIS
Rough surface (Trachonychia )
Distal onycholysis Oil Staining
PSORIASIS
Punctate Leukonychia
Pathognomic Traumatic subungual
haemorrhage
PSORIASIS
Oil staining Longitudinal ridging Distal onycholysis Adherence of cuticle
to distal nail plate
PSORIASIS
Spongitic Pustule seen in Epidermis Absence of Granular layer,Acanthosis of Epidermis,Vascular Changes
LICHEN PLANUS
Nail involvement seen in 10 % of patients with LP
Nail thinning,ridging & fissuring Cicatricial out come ( Dorsal
Pterygium ) Yellowish discolouration Onycholysis
LICHEN PLANUS
Middle Finger : Proximal nail fold and matrix caused trachonychia,Longitudinal ridging,pterygium
Index Finger : Destruction of Nail Plate & Matrix with anonychia
LICHEN PLANUS
Involvement of nail matrix with pterygium
Scarring Pt had Hepatitis C
virus with erosive lichen planus
LICHEN PLANUS
Involvement of nail matrix
Thinning of thumbnail plates
LICHEN PLANUS :
Lichenoid infiltrate of nail bed and distal nail matrix * ,Nail plate
LICHEN PLANUS
HYPERKERATOSIS & SUPERFICIAL LYMPHOCYTIC INFILTRATE
BAND LIKE SUPERFICIAL LYMPHOCYTIC INFILTRATE ALONG WITH VACUOLAR DEGENRATION
DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS) Nail involvement in 96% cases Red or white longitudinal streaks ending in
a V shaped notch Streaks indicative of nail thinning Subungual hyper keratotic papules in
hyponychium Histologically similar to acantholysis of
skin in addition of multinucleated giant cells,epithelial hyperplasia seen
A case of SCC developing in chronic case of darier disease also noted
DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS)
Longitudunal streaks ( red & white )
Distal subungual hyperkeratotic papules
Wedge shaped fissuring of nail plate
DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS)
White and Red Longitudinal streaks
Distal notching
RED LUNULA Erythema of all or part of the lunula
may affect all digits, but most prominently the thumb
Dotted red lunulae have been reported in psoriasis and alopecia areata
red lunula seen in a single digit-Local disturbance of vascular flow- Benign tumour
Glomus tumour & Subungual myxoid cysts MC tumours.colour vary from blue & red
YELLOW NAIL SYNDROME The nails are yellow due to
thickening,rarely green tinge possibly due to secondary infection
There is increased transverse & longitudinal curvature,loss of cuticle & Lunula obscured
AD A/w lymphoedema at one or more
sites and respiratory or nasal sinus disease
YELLOW NAIL SYNDROME Histologically dense fibrous tissue
replacing Subungual stroma with numerous ectatic epithelium lined vessels,FB reaction may be seen
Obstruction of lymphatics by dense stroma leads to the abnormal lymphatic function found in the affected digits
Recurrent pleural effusions,Ch bronchitis, bronchiectasis,increased incidence of malignant neoplasms,nephrotic syndrome
YELLOW NAIL SYNDROME
Nails grow at slower rate 0.1-0.25 mm/week ( normal rate 0.5mm/week )
YELLOW NAIL SYNDROME
Diffuse Yellow to Green of nails
Nail thickening Excessive curvature
of from side to side
YELLOW NAIL SYNDROME
Treatment : Oral & Topical Vit E Oral & Topical Zn Pulse Itraconazole 400mg daily
/week/month Treatment of Chronic infection Complete reversion of nail changes
may occur spontaneously
HUTCHINSON’S SIGN
Brown black periungual pigmentation Possible sign of nail melanoma First described by
Hutchinson ,Pigmentation of proximal nail fold in a/w longitudinal melanonychia
Also identified in melanocytic naevi
HUTCHINSON’S SIGN
GREEN NAIL SYNDROME
Greenish black discolouration d/t Pyocyanin by P. aeruginosa
Exposure to water,detergents & soaps Barbers,Bakers & Dish washers DD: Melanoma,Aspergillus,Melanocytic
naevus Rx:Aminoglycosides,Acetic acid for 1 to
4 months
MEE'S LINES
Transverse white lines that run across the nail, following the shape of the nail moon
Uncommon after acute/severe illness, Arsenic
poisoning
MEE'S LINES
BROWN – GRAY NAILS
CYANOSIS
A bluish discoloration visible at the nail bases
patient with severe hypoxemia or hypoperfusion.
CYANOSIS
HALF-&-HALF NAILS
K/a Lindsay's nails Look for an arc of brownish
discoloration May occur in a small percentage of
people who have ch renal failure Other causes systemic diseases &
nutritional deficiencies
HALF-&-HALF NAILS
SPLINTER HAEMORRHAGES
Looks like a splinter underneath the nail
virtually 100% diagnostic of Sub-acute
Bacterial Endocarditis (SBE)
A bacterial infection affecting the
valves of the heart. Occasionally
caused by Trichinosis, a parasitic
infection caused by eating raw or
undercooked Pork.
SPLINTER HAEMORRHAGES
MELANONYCHIA
vertical pigmented bands or nail 'moles‘
a sudden change in the nail plate could indicate a malignant melanoma or lesion.
Commonly occur in dark-skinned people, and are normal
Seek physicians care ,If you suddenly see this change in the nail plate.
MELANONYCHIA
LEUKONYCHIAWHITE DISCOLOURATION OF NAILS
True Leukonychia:Inherited disorder,all nail
affected,milky porcelian white nails
Subtotal Leukonychia :Proximal 2/3rd white rest pink
d/t delay in keratin maturation
Transverse Leukonychia: k/a Mees lines reflect
systemic disorder,chemotheraphy,poisining
Punctate Leukonychia:White spots of 1-3 mm
size,Manicure,alopecia areata
Apparent Leukonychia:Changes in nail bed
responsible for white appearance
Terry’s Nails: white proximally,normal distally,seen in old age,chronic renal failure,afterchemotheraphy,cirrhosis,cardiac failure,histology shows Inc vessel wall thickness & Melanin deposition
Muehrcke’s paired white bands : bands parallel to lunula in nail bed with pink in b/w white lines,seen in hypoalbuminaemia
LEUKONYCHIAWhite nails in distal free edges
TERRY'S NAILS
The nail looks opaque and white, but the nail tip has a dark pink to brown band.
May accompany cirrhosis, congestive heart failure, adult-onset diabetes, cancer or ageing.
ECZEMA OF THE NAIL
It affect the eponychium, nail plate and bed It causing pitting and onycholysis.
This is very rare
Eczema
HANG NAILS
Caused by minor injury or constant irritation through biting. The cuticle splits and appears as a small spike.
Hot oil manicures and regular use of a cuticle oil will help.
The spike can be clipped so it does not catch on things.
EGGSHELL NAIL
Nail plate is thin and abnormally flexible
chronic illness of systematic or nervous origin
It curves at the free edge and the nail plate can separate from the nail bed
ONYCHOLYSISDISTAL OR LATERAL SEPARATION OF NAIL FROM NAIL BED
Psoriatic onycholysis considered as a reference point for other forms
PO-typically distal,variable lateral involvement,area of separation appear white or yellow due to air beneath the nail,sequestered debris & glycoprotien exudate
Isolated islands of onycholysis present as Oil spots , salmon patches
ONYCHOLYSIS
Idiopathic-Painless separation of nail
from its bed-Overzealous manicure,wetting,cosmetic solvents-Condition starts at tip of
nail,spreads to distal one third of nail bed
-Colonization of candida albicans & pseudomonas pyocyanea
-Affected nails grow very quickly,more in women,
Secondary Psoriasis,trauma,funga
l infections,dermatitis,hypothyroidism,yellow nail syndrome,shell nail syndrome
- Photoonycholysis : treatment withpsoralens,doxycycline,demethylchlortetracycline,retinoids,anti cancer drugs
ONYCHOLYSIS
Distal onycholysis Loss of cuticle Psoriasis may be
cause
ONYCHOLYSIS
Most commonly associated with external trauma to the nail
Nail plate separates from the nail bed
ONYCHOLYSIS
The subungual space may be filled with hyperkeratotic debris
Distal nail bed separated from the nail plate in 2 nails.
ONYCHOLYSIS
Treatment : Patient advised cut away loosened nail &
apply local steroid with antibiotics ( prevent keratinisation of nail bed,that slows reattachment of nail)
Gentamicin eye drops for pseudomonas infection
2% thymol in chloroform for preventing infection
Milton regimen : soaking finger tips several nights week in venegar or sodium hypochlorite solution for 5 mins for prevention of recurrence
ONYCHOMYCOSIS A fungal or yeast infection which results in
Onychomycosis, can invade through a tear in the proximal and lateral nail folds as well as the eponychium.
This type of infection is characterized by onycholysis with evident debris under the nail plate.
It normally appears white or yellowish in color, and may also change the texture and shape of the nail.
The fungus digests the keratin protein of which the nail plate is comprised. As the infection progresses, organic debris accumulates under the nail plate often discoloring it.If left untreated, the nail plate may separate from the nail bed and crumble off.
ONYCHOMYCOSIS(TINEA UNGUIUM)
White spots that can be scraped off the surface, or long yellowish streaks within the nail substance.
It attacks the free edge & moves towards the matrix
ONYCHOMYCOSIS
TINEA UNGUIUM – NAIL INFECTION
ONYCHOMYCOSIS
DSO
Distal subungual
hyperkeratosis and onycholysis involving most of the nail bed
of the great toenails; these
findings are usually
associated with tinea pedis.
Onychomycosis
ONYCHOMYCOSIS
NAIL CLIPPINGS SHOW SEPTATE HYPHAL ELEMENTS PROVEN TO BE TRICHOPHYTON SP WITH IN NAIL PLATE KERATIN
90 % Toe nail infections with Trichophyton,Microsporum,Epidermophyton sp
PAS staining most sensitive test
Stain reveals fungal organisms located in lower stratum corneum
Distal subungual Onychomycosis is MC form,caused by T.rubrum
It invades hyponychium & LNF finally yellow,onycholysis,sub ungual hyperkeratosis
T.mentagrophytes identified in superficial white OM,located in superficial nail plate
ONYCHOPHAGY
Bitten nails, often no free edge is visible
Nails look ragged and distorted
skin and nail bed can be exposed and raw
ONYCOPHOSIS
Refers to the growth of the horny epithelium in the nail bed
In other words a callus like growth on the nail plate
ONYCHOGRYPHOSIS
Elderly,Commonly toenails,usually Hallux
Favored by trauma Impairement of peripheral circulation
and innervation Nail acquires typical Ram’s Horn
shape d/t asymmetric growth Thick,hard,yellow brown nails
ONYCHOPTOSIS
Periodic shedding of one or more nails, either in whole or parts
This condition may follow certain diseases such as syphilis
PARONYCHIA
Paronychia is associated with separation of the seal between the proximal nail fold and the nail plate that provides entry for bacteria and leads to a localized infection of the paronychial tissues of the hands.
Symptoms may include inflammation, swelling & scaling
PARONYCHIA
An infectious and inflammatory condition of nail folds. Infection is bacterial
Ch paronychia may weaken defences and increase the risk of developing a fungal infection of the nail
PARONYCHIA
The nail fold is
erythematous, edematous,
with early abscess
formation, and is very
painful.
Paronychia
PTERYGIUM
Pterygium is the inward advance of skin over the nail plate,
Usually as a result of trauma to the matrix due to a surgical procedure or by a deep cut to the nail plate
Pterygium results in the loss of the nail plate due to the development of scar tissue
Cortisone is used to prevent the advancement of scar tissue. Never attempt to remove pterygium -instead, consult a physician for advice and treatment
NOTE: The 'true cuticle' is often referred to as Pterygium
PTERYGIUM Pterygium Inversum Unguis is an
acquired forward growth of the hyponychium characterized by live tissue firmly attached to the underside of the nail plate, which contains a blood supply and nerves.
Possible causes are systemic,
hereditary, or from an allergic reaction to acrylics or solvents.
Never use force to 'push back' the advancing hyponychium -- it is an extremely painful approach, and will result in a blood flow.
PTERIGIUM
An abnormal winged like growth of skin (living tissue) on the nail plate
The skin is slowly stretched and dragged along the bed
caused by severe trauma such as warts, burns & blood circulation disorders.
PTERYGIUM
DORSAL PTERYGIUMVENTRAL PTERYGIUM
SCABIES OF NAIL
Commonly identified in crusted scabies Heaped up masses of keratin
accummulate underneath the nail Subungual material contains abundant
mites,source of infection Nails become dystrophic
SCABIES OF NAIL
SCABIES OF NAIL
Sarcoptes scabiei present in distal subungual hyperkeratotic debris found in hyponychium
Cause of persistent epidemics of scabies
Norwegian scabies severe involvement of nail folds
Scrapings of distal hyponychium- showing organism – Sarcoptes Scabiei
CANDIDA
Candida parapsilosis account for 20% infections
Candida common cause of Chronic paronychia,involve nail bed & nail plate in HIV
Candida albicans major cause of hypertropic nail bed infection in paediatric patients with HIV
CANDIDAL PARONYCHIA
MUCOCUTANEOUS CANDIDIASIS
CANDIDA
NAIL CLIPPINGS SHOW BUDDING YEASTS
PSEUDOMONAS
Pseudomonas bacterial infection can occur between the natural nail plate and the nail bed
Many people have been led to believe that the classic 'green' discoloration of this type of infection is some type of mold
In actuality, mold is not a human pathogen. The discoloration is simply a by-product of the infection and is caused primarily by iron compounds
PSEUDOMONAS
Pseudomonas thrive in moist places; it feeds off the dead tissue and bacteria in the nail plate, while the moisture levels allow it to grow
The after effects of this infection will cause the nail plate to darken and soften underneath an artificial coating
PSEUDOMONAS
The darker the discoloration, the deeper into the nail plate layers the bacteria has traveled. If the bacteria has entered between the nail plate and the nail bed, it will cause the same discolorations and may also cause the nail plate to lift from the nail bed.
PSEUDOMONAS
pseudomonas colonisation
ALOPECIA AREATA
First sign in 18% cases,More in children Pitting of nails,When pits uniformily
distributed on multiple nails,they often arranged in lines horizontially or vertically in a geometrical design k/a Glen-Plaid or Scotch-Plaid Pattern
ALOPECIA AREATA
SCOTCH-PLAID PATTERN
ASSESSING NAIL DISORDERS
Social History Footwear Medical History Physical exam Nail Assessment Special Investigations
SOCIAL HISTORY
Smoking Occupation Recreational Activities Places of residences (Qsld)
FOOTWEAR
Occupational Recreational Historical May need to inspect footwear
MEDICAL HISTORY
Need to conduct a review of systems (ROS) Dermatological Conditions important
eg psoriasis, atopy, Multi-System Disorders
eg RA, SLE, DE, CREST Cardiac/Pulmonary Problems Medications review Surgical Review Genetics review
PHYSICAL EXAMINATION
Vascular macro/micro circulation
Neurological Deficits?
Dermatological Below Knee
Gait Assessment
SUBJECTIVE NAIL ASSESSMENT
Events of Note How long has problem been present? Is it getting better or worse? Is it of concern to the client? Is pain present?
If so need to evaluate pain What previous treatments have been attempted?
Professional OTC Folk Need to follow up if any of these answers is positive
OBJECTIVE ASSESSMENT OF NAILS
Number of nails affected? Hands involved? Colour changes Extent of colour changes Extent of general changes Presence of toe deformity Presence of local exostosis May need to examine other areas
Scalp, elbows, knees
SPECIAL INVESTIGATIONS
Nail Specific Biopsy Microscopy (KOH test) Culture
X-Ray Blood Tests Further Vascular/Neurological Testing Cardiac Evaluation Genetic Testing
COMMON AETIOLOGIES
Trauma Infection
Fungal Bacterial
Systemic Disorders Direct Indirect
Neoplasms