Nail changes on different Disease

Jeetendra Bhandari

PSORIATIC NAILS

Introduction

• 10-15% of patients with psoriasis have nail involvement.

Nail changes includePitting (small, regularly placed pits, as on a thimble)

Nail plate thickening (tunneled nail plate)

Subungual hyperkeratosis (accumulation of keratinous material which does not break)

Discoloration and dystrophy of nail plate (nail plate becomes yellow or brown and dystrophic)

Onycholysis (separation of nail plate from the nail bed)

Oil spot (due to nail bed psoriasis and is specific for psoriasis)

Thimble-like pitting of nails with onycholysis Onycholysis

ONYCHOMYCOSIS

Introduction

• Fungal infection of nails

• Toe nails more frequently involved than finger nails

• Caused by dermatophytes (Trichophyton rubrum commonest)

• Involvement starts at distal edge and spreads proximally

• Nail plate is yellow and thick and crumbles easily (so is tunneled)

• Subungual hyperkeratosis, which is friable

Onychomycosis of toenails: distal and lateral subungual type (DLSO)

Tinea unguium: proximal subungualonychomycosis type (PSO)

Onychomycosis of toenails:superficial white type (SWO)

Differentiated fromPsoriasis of nails Onychomycosis

Symmetry: symmetrical involvement of several nails

Asymmetrical involvement of few nails

Site: begins proximally Usually begins distally

Pitting: very frequent Not seen

Nail plate: thickened and discolored Thickened, discolored and tunneled

Subungual debris: does not crumble it is firm Friable

• Investigations

- Potassium hydroxide preparation of nail clippings shows fungal hyphae

- Culture for fungus

• Management

- Systemic- Terbinafine, Itraconazole, Grsefulvin

- Topical- Amorolfine/ciclopirox

Alopecia Areata

Introduction

• Affects 10-50% of those with alopecia areata

• Pitting and thinning of nail plate are the most common findings

• predominantly of the fingernails

• Hammered brass appearance

• Trachonychia ( roughness caused by excessive longitudinal striations)

Alopecia areata: trachonychia The nail plate isrough with a “hammered brass” appearance.

Nails can have dents, white spots, and roughtness.

Lichen planus

• Seen in 15% of patient (less frequently in children)

• 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 lichenplanus elsewhere on the body).

• Thinning and distal splitting of nail plates, longitudinal ridging

• Tenting of nail plate (pup tent sign)

• Trachyonychia: characterized by nail roughness due to excessivelongitudinal ridging( sand paper nails)

• Pterygium: It is diagnostic. Proximal nail fold is prolonged on to thenail bed, splitting and destroying the nail plate.

Middle finger: Involvement ofthe proximal fold and matrix has causedtrachonychia, longitudinal ridging,and pterygium formation.

Involvement of the nail matrix withscarring or pterygium formation proximally dividing the nail plate intwo

Early involvement of the matrix with thinningof the thumbnail plates.

nail plate is completely destroyed, i.e., anonychia

Chronic Eczema

Features

• Nail changes may develop with pompholyx or chronic eczema of hands and/or feet.

• Patients may have a genetic tendency to atopic eczema and/or pompholyx eczema.

• May result from outside factors such as stress, handling irritant substances, frequent immersion in water or contact allergies.

• May occur at any age. Usually patients have a history of long-standing eczema.

• Irregular transverse ridging.

• Pitting, thickening and discolouration.

• Other signs of eczema of the hands or feet affected.

• Usually a clinical diagnosis. Investigations not usually necessary except allergy testing and nail clippings to exclude fungal infection.

•Deformities, nail brittling,atrophic and hypertrophic changes may occure•Spooning of nail

Reference

• FITZ PATRICK’S COLOR ATLAS AND SYNOPSIS OF CLINICAL DERMATOLOGY SIXTH EDITION

• Dermatology by Neena Khanna

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