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Hitting the Nail on the Head: Clues to Systemic Disease
Scott Sears, MD FACP
Internal Medicine Associates
Billings, MT
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Transverse linesA) Muehrcke’s Lines
B) Beau’s Lines
C) Leukonychiapunctata
D) Mee’s Lines
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Muehrcke’s Lines
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Muehrcke’s LinesWhat it is:• an abnormality of the vascular nail bed
What you see:• pairs of transverse white lines that extend all the
way across the nail (parallel to lunula)• it goes away with nail pressure• it does not grow out
• What it’s associated with:• hypoalbuminemia (albumin <2)• nephrotic syndrome • malnutrition• cirrhosis
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Beau’s lines
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Beau’s lineWhat it is:• representation of nail growth arrest
What you see:• deep transverse grooves in the nail(s)• can be single or multiple• it does grow out• the longer the insult, the wider the groove
• What it’s associated with:• trauma• chemotherapy• systemic illness
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Leukonychia Punctata
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Leukonychia PunctataWhat it is:• minor trauma to nail cuticle or matrix
What you see:• non-uniform lines or spots• can be single or multiple• it does grow out
What it’s associated with:• minor trauma
When did this trauma occur?
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Mee’s lines
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Mee’s linesWhat it is:• nail bed ok but nail itself is microscopically
fragmented
What you see:• milky white transverse bands• seen in single or multiple nails• grow distally with time• width varies with the insult
• What it’s associated with:• heavy metal poisoning (arsenic, thallium)• leprosy• malaria• carbon monoxide poisoning• renal and heart failure• chemotherapy• Hodgkin’s disease
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Longitudinal LinesA) Longitudinal
ridging
B) Splinter hemorrhages
C) Melanoma
D) Pigmented bands
E) Habit tic deformity
F) Median nail dystrophy
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Longitudinal Ridging
What it is:• partial dropout or malfunction of the nail matrix, which thins the nail plate
What you see:• longitudinal elevations that alternate with depressions or grooves along the nail
• What it’s associated with:• being elderly• lichen planus (can be severe)• not associated with vitamin deficiencies
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Melanoma vs. pigmented bands•New longitudinal band in a light-skinned person
•Sudden change in appearance of band (e.g., proximally wider, darker, blurred border)
•Single-nail involvement (especially thumb, index finger, or great toe)
•Pigmentation of the skin of the nail fold or proximal nail bed (Hutchinson's sign)
•New pigmentation in older persons (>60)
•Band width of more than 3 mm
•Family history of melanoma or dysplastic nevi
•Abnormal nail structure (i.e., destruction or disruption of the nail plate)
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Splinter Hemorrhages
What it is:• hemorrhage of the distal capillary loop
What you see:• longitudinal hemorrhage
• What it’s associated with:• subacute bacterial endocarditis• trauma (usually distal)• lupus, RA, APLA• pregnancy• psoriasis
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Median nail dystrophy, habit-tic deformity, and splitting
Damage to the matrix
Self-inducedBenign
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Nails and Colors
A) Terry’s nails
B) Trauma
C) Pseudomonas
D) Yellow nail syndrome
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Terry’s nailsWhat it is:• due to a decrease in vascularity and an increase in connective tissue in the nail bed
What you see:• white nails except for distal pink band• loss of the lunula• usually all the nails
• What it’s associated with:• Cirrhosis (80% of cases)• Diabetes• CHF• Hyperthryoidism• Malnutrition
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Pseudomonas vs. Trauma
Treatment:• cut the nail as far back as possible.
• apply gentamicin otic solution bid
• alternatives include soaking in vinegar or treating with oral cipro(500mg bid x 2 weeks)
• may need to co-treat for fungal infection
Treatment:• bore a sterile hot needle through the base of the nail
• make sure you are wearing ocular protection
• almost instant relief
• watch for Beau’s lines to develop!
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Yellow nail syndromeWhat it is:• delayed nail growth with associated microvascular permeability
What you see:• yellow, thickened nails• can see loss of the lunula• usually all the nails
• What it’s associated with:• Lymphedema• Pleural effusion• Hypoalbuminemia• Bronchiectasis• RA
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Fun pimping
• How do you detect clubbing?
• What is the sign called?
• What conditions are associated with clubbing?
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Clubbing
Associated conditions: Inflammatory bowel disease, lung cancer, asbestosis, chronic bronchitis, COPD, cirrhosis, congenital heart disease, endocarditis, fistulas
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Nail biting
What is the single best lifestyle modification to prescribe?
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Nail biting
What is the single best lifestyle modification to prescribe?
Increased physical activity!!!
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Spoon nails - Koilonychia
What are the two most common conditions associated with spoon nails in adulthood?
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Spoon nails - Koilonychia
What are the two most common conditions associated with spoon nails in adulthood?
1. Iron deficiency (Plummer-Vinson syndrome)
2. Hemochromatosis
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Periungal telangectasias
What group of disorders is most commonly associated with periungal telangectasias?
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Periungal telangectasias
What group of disorders is most commonly associated with periungal telangectasias?
Connective tissue diseases, especially scleroderma
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References
• Fawcett et al. Nail Abnormalities: Clues to Systemic Disease. Am Fam Physician 2004;69:1417-24.
• Dermnet.com (for images of several nail disease)
• Habif. Clinical Dermatology. 4th edition.