INTRODUCTION

Nail cosmetology, as it is evolving today, is a fairly recent development. Fancy

and fantasy have entered nail fashions, with the nails being subjected to a variety of
onslaughts. In some segments of the society, the color and the shape of the nail has
become a measure of a women's personality and 'appeal' and an index of her
vibrancy.1
Cosmetics and cosmetology apart, the nail is an interesting organ of the human
body. While it can be argued whether the nail should be considered as an organ in the
strictest sense of the term, that the nail serves some important physiological and social
functions cannot be denied. The chief function of the nail in man is that of
protection2. It protects the terminal phalanx and the fingertip and gives precision and
delicacy in picking up small objects. The nail also serves to augment the sensation of
touch. Nails are of course best useful for what perhaps they were meant to do,
scratching that is!
Nail disorder comprises approximately 10% of all dermatological conditions.
The nail unit may show specific changes that are markers for a wide range of systemic
disorders. Further, there are a number of heritable and non-heritable syndromes in
which the nail disease is an integral part of multisystem disorder. Sometime a
developmental defect may be limited to the nail. Additionally, a number of
dermatological disorders may affect nail. Consequently no physical examination is
complete without detail examination of nail. However the nail still remains an
understudied, underutilized yet quiet accessible structure that lends itself for
examination and evaluation.
The study of nail abnormality may contribute considerably to the art of
diagnostic medicine. Hence this study was undertaken to know the various nail
changes and correlate them with dermatological and systemic diseases.

AIMS & OBJECTIVES

1) To study nail changes in patients attending dermatology OPD and patients
referred from other wards of hospital.
2) To make an attempt to correlate nail changes with dermatological & systemic
diseases.
3) To confirm the diagnosis with the help of appropriate investigations in
relevant cases, especially in infectious diseases like fungal infection.
4) To know the effect of occupation on nail diseases.

REVIEW OF LITERATURE
BIOLOGY OF NAILS3
The nail apparatus consists of a horny "dead" product, the nail plate, and four
specialized epithelia: the proximal nail fold, the nail matrix, the nail bed, and the
hyponychium.

Nail Plate
The nail plate is a fully keratinized structure that is continuously produced
throughout life. It results from maturation and keratinization of the nail matrix
epithelium and is firmly attached to the nail bed, which partially contributes to its
formation. Proximally and laterally the nail plate is surrounded by the nail folds. At
the tip of the digit, the nail plate separates from the underlying tissues at the
hyponychium. The nail plate is rectangular, translucent, and transparent.
The proximal part of the finger nails, especially of the thumbs, shows a
whitish, opaque, half-moon-shaped area, the lunula, that is the visible portion of the
nail matrix.
In transverse sections, the nail plate consists of three portions: dorsal nail
plate, intermediate nail plate4, and ventral nail plate. The dorsal and the intermediate
portions of the nail plate are produced by the nail matrix, whereas its ventral portion is
produced by the nail bed.
The mean toenail thickness at the distal margin is 1.65 0.43 mm in meaji and
1.38 0.20 mm in women. Fingernails are thinner; the mean thickness is 0.6 mm in
mean and 0.5 mm in women. There is an increase in nail thickness with age
particularly in the first two decades.

Proximal Nail Fold

The proximal nail fold is a skin fold which consists of a dorsal and ventral
portion. The dorsal portion is anatomically similar to the skin of the dorsum of digit
but thinner and devoid of pilosebaceous units. The ventral portion, when cannot be
seen from the exterior and proximally continues with the germinative matrix, covers
approximately fourth of the nail plate. It closely adheres to the nail plate surface and
keratinizes with a granular layer. The limit between the proximal nail fold and the nail
matrix can be histologically established at the site of disappearance of the granular
layer.

Nail Matrix
The nail matrix is a specialized epithelial structure that lies above the midportion of the distal phalanx. After elevation of the proximal nail fold, the matrix
appears as a distally convex crescent with its lateral horns extending proximally and
laterally.
In longitudinal sections the matrix has a wedge-shaped appearance and
consists of a proximal (dorsal) and a distal (ventral) portion. Nail matrix keratinocytes
divide in the basal cell layer and keratinize in the absence of a granular zone. 5 In some
conditions nuclear fragments may persist within the intermediate nail plate, producing
leukonychial spots.
Maturation and differentiation of nail matrix keratinocytes do not follow a
vertical axis, as in the epidermis, but occur along a diagonal axis that is distally
oriented. For this reason, keratinization of the proximal nail matrix cells produces the
dorsal nail plate and keratinization of the distal nail matrix cells produces the
intermediate nail plate.
In some fingers the distal matrix is not completely covered by the proximal
nail fold but is visible through the nail plate as a white half moon-shaped area, the
lunula. The white color of the lunula results from two main anatomic factors: (1) the
keratogenous zone of the distal matrix contains nuclear fragments that cause light
diffraction; (2) nail matrix capillaries are less visible than nail bed capillaries because
of the relative thickness of the nail matrix epithelium6.

NAIL BED
The nail bed extends from the distal margin of the lunula to the onychodermal
band and is completely visible through the nail plate. The nail bed epithelium is thin
and consists of two to five cell layers. Nail bed keratinization produces a thin horny
layer that forms the ventral nail plate. Nail bed contribution to nail plate formation
corresponds to approximately one fifth of the terminal nail thickness and mass 7. In
pathologic sections, the ventral nail plate is easily distinguishable because of its light
eosinophilic appearance. Nail bed keratinization is not associated with the formation
of a granular layer. This may appear, however, when the nail bed becomes exposed
after nail avulsion5.

Hyponychium
The hyponychium marks the anatomic area between the nail bed and the distal
groove, where the nail plate detaches from the dorsal digit. Its anatomic structure is
under normal conditions the water content of the nail plate is 18 percent, and most of
the water is in the intermediate nail plate. When the water content decreases below 18
percent, the nail becomes brittle; when it increases above 30%, it becomes opaque and
soft8.

Physical Properties
The nail plate is hard, strong, and flexible. The hardness and strength of the
nail plate are due to its high content of hard keratins and cysteine-rich high-sulfur
proteins; whereas its flexibility depends on its water content and increases with nail
plate hydration9. The double curvature of the nail plate along its longitudinal and
transverse axes enhances nail plate resistance to mechanical stress10.

Nail Growth
The nail plate grows continuously throughout life of an individual. Fingernails
grow faster than toenails, with a mean growth of 3 mm/month for fingernails and 1
mm/ month for toenails. Complete replacement of a fingernail requires 100 to 180
days (6 months). When the nail plate is extracted, it is approximately 40 days before

the new fingernail first emerges from the proximal nail fold. After a further 120 days
it will reach the fingertip. The total regeneration time for a toenail is 12 to 18 months.
Physiological and pathological factors affecting nail growth.
Faster growth
Day
Right hand
Youth
Fingers
Summer
Male
Middle, index finger nails
Minor trauma and avulsion
Pregnancy

Slower growth
Night
Left hand
Old age
Toes
Winter
Females
Thumb, little finger
First day of life
Lactation

Classification of nail disorders1

Classification 1
Genetic / developmental disorders of the nail
Dermatologic diseases of the nail unit
Nail changes due to systemic diseases
Nail changes due to trauma
Tumours of nail
Infections of nail
Nail changes due to drugs

Classification 2
Abnormalities of shape
Abnormalities of nail attachment
Abnormalities of nail surface
Abnormalities of nail color

Genetic / developmental disorders of the nail

Diseases limited to the nail
Congenital
Anonychia
Racket nails
Congenital pitting
Ridging
Micronychia Macronychia
Polyonychia
Onychoheterophoria
Hereditary
Hereditary clubbing
Periodic shedding

Diseases in multiple organ systems of

ectodermal or mesodermal origin
Hidrotic ectodermal dysplasia
Pachyonychia congenital
Chondroectodermal dysplasia

Nail patella syndrome

Epidermolysis bullosa
Darners disease
Dyskeratosis congenital
Progeria

Tuberous sclerosis
Pachydermoperiostitis
Rothmond Thomson syndrome
Dermatologic diseases of the nail unit
Localized

Systemic
Connective tissue disease

Psoriasis
Lichen planus
Alopecia areata
Eczema
Pemphigus vulgaris
Reiters disease
Nail changes due to systemic diseases

Associated with cardiac, vascular and hematologic disorders

Associated with gastrointestinal and hepatic disorders
Associated with endocrinal disorders
Associated with diabetes mellitus
Associated with neurological disorders
Associated with systemic chemical poisoning

Nail changes due to trauma

Nail biting
Pincer nails
Habitic deformity
Ingrowing toe nail
Median nail dystrophy of Heller
Onychogryphosis
Skiers toe
Splinter hemorrhage
Onychotillomania
Onychoschizia
Nail hypertrophy
Tumours of Nail
Benign

Malignant

Subungual exostosis
Ganglion cyst
Glomus tumour
Pyogenic granuloma Angioma
Fibroma
Onychomatric oma
Actinic keratosis
Clavus
Enchondroma

Local
Squamous cell carcinoma
Melanoma
Bowen disease
Basal cell epithelioma
Sarcoma

Systemic
Metastic cancer
Lymphoma

Infections of nails
Localized process
Bacterial infections
Staphylococcus aureus
Streptococci
Pseudomonas
Mixed bacterial and fungal infection
Fungal infection
T.rubrum
T. mentagrophytes
E.fluoccosum
Yeast infections
Candida albicans
Spirocheatal
Viral
Warts, molluscum contagiosum, herpes simplex

Systemic process
Septicemia and septic emboli

Candidiasis

Nail changes due to drugs like

Anticancer drugs

Psoralens

Antiepileptic drugs

Retinoids

Antimicrobial drugs

2nd Classification
Abnormalities of

Abnormalities

shape
Clubbing

nail attachment
Nail shedding

of Abnormalities

of

nail surface
Longitudinal

Abnormalities of
nail color
Leukonychia

grooves
Koilonychia

Onycholysis

Transverse groove

Longitudinal

and beaus lines

melanonychia

Pincer nails
Anonychia

Pterygium
Pterygium ungium

Elkonyxis
Pitting

Mees lines
Muehrckes lines

Brachyonychia
Micronychia and

inversus
Hang Nails
Subungal

Onychoschizia
Onychorrhexis

Half and half nail

Terry nail

Macronychia
Polyonychia

hyperkeratosis
Nail thickening

Trachyonychia

Red / blue lunulae

Onychogryphosis
Onychomadesis

Beading and

Longitudinal

ridging

erythronychia
Splinter

Ungium incarnates

haemorrhages
Longitudinal
melanonychia
Yellow nail

Developmental disorders of the nail unit1

Anonychia1:
Anonychia or absense of nails is a rare congential anomaly. It may present as an
isolated symptom or be a part of other developmental defects that are sometimes
hereditary. Anonychia may not be complete and often there are rudimentary nails on
some fingers and toes (hyponychia).
Anonychia has been described in association with nail patella syndrome, DOOR
syndrome, AEC syndrome, EEC syndrome, Coffin-Siris syndrome, TOOD syndrome,
hyphohidrotic ectodermal dysplasia with multiple anomalies and various craniofacial
malformation syndromes.
Brachyonychia (Racket nails)1
Racket nail is a common developmental anomaly that is inherited as an autosomal
dominant trait. Girls are more frequently affected than boys. It may affect any finger
but the thumbs are more commonly involved. In affected individuals the epiphyses of
the terminal phalanx of the thumbs close prematurely, at the age of 7-10 years
(normally they close at 13-14 years in girls and a little later in boys). Therefore, the
distal phalanx of the affected thumb is shorter and wider than normal and the nail only
conforms to the altered shape of the thumb. The affected nails are opaque and are
short and wide with loss of normal and the nail only conforms to the altered shape of
the thumb. The affected nails are opaque and are short and wide with loss of normal
curvature. Racket nails may also occur without any underlying bone anomaly.
Micronychia / Macronychia:
Nail that are normal in all other respects, but small or larger in size as compared with
other nails. Micronychia seen in Isokikuchi syndrome, Turners syndrome.
Macronychia seen in Von-Recklinghausens syndrome, Maffuci syndrome.
Polyonychia:
The existence of 2 or more separate nails on 1 digit seen in Lawrence Moon Biedel
syndrome.

Ectopic nail (syn: Onychoheterotopia)1:

Is a term used to describe nail tissue noted in a different location other than in the
normal nail bed. It is an extremely rare condition. It has been classified as congenital
and acquired. They have also been noted in associated with congenital anomalies like
Pierre Robinson syndrome and in patients with anomalies of chromosome 6. Acquired
ectopic nails occur following trauma to the nail unit and hence it has been postulated
that the transfer and inoculation of the nail matrix causes ectopic nail growth. The
treatment of ectopic nail is surgical excision.
Pachyonychia congenita 12,13,14
Rare hereditary (autosomal dominant) ectodermal dysplasia characterized by nail
hypertrophy and dyskertosis of skin, mucous membrane due to mutation in keratin 16
and 17. It is of 4 types.
Type 1: (Jadasson Lewandowsky). Most common type. Nail progressively thickens
from base to tip to become wedge shaped. Associated with palmoplantar
hyperkeratosis, warty lesions on the knees, buttocks legs and popliteal fossa. There is
oral and corneal dyskertosis. It occurs due to missense mutation in keratin 16 gene
found in PC-1.
Type 2: Nail thickening is uniform and nail is infected with Candida. Chronic oral
candidiasis is present. It is associated with natal teeth, multiple epidermal cyst,
steatocystoma, dry lusterless kinky hair, and eyebrow that stand straight out,
hamartoma. It is due to missense mutation in helix initiation motif of keratin 17 gene.
Type 3: (Jackson Lawler): Nail thickening and keratosis is less serverthan type 1 and
Type 4: Moderate severe nail thickening and keratosis associated with widespread
macular pigmentation over neck and axilla.
Type

Nail

findings
Nail hypertrophy nail
dystrophy

Additional findings

Palmoplantar keraoderma, follicular

Prevalence
56.2%

keartosis, oral leukokeratosis

2

Clinical features and

Bullae of palms and soles

24.9%

type oral lesions and

hyperhidrosis neonatal teeth,

keratoderma rare
Same as type 2

steatocystoma multiplex
Angular

cheiltis,

corneal

11.7%

dyskeratosis, cataract
4

Same as type 1, 2, 3

Laryngeal lesions, mental retardation,

alopecia

7.2%

Congenital disorders of the nail unit:

Nail patella syndrome (Hereditary Osteoonychodysplaia, Fong syndrome)
Nail-patella syndrome (NPS), also known as hereditary osteo-onychodysplasia
(HOOD), is an uncommon genetically determined disease that involves organs of both
ectodermal and mesodermal origin. Chatelain described NPS in 1820, and Little first
documented its hereditary nature in 1897. . Mutations in the gene encoding
transcription factor LMX1B, mapped on the long arm of chromosome 9 (9q34), are
responsible for the clinical phenotype of NPS13. The diagnostic tetrad includes
fingernail dysplasia, absent or hypoplastic patellae, the presence of posterior conical
iliac horns, and deformation or luxation (i.e., hypoplasia) of the radial heads. Nail
dysplasia and patellar hypoplasia are essential findings for diagnosis. Other diagnostic
features are hypoplasia of the radial head and iliac prominences, which are known as
iliac horns.16,17

Nails
o Patients have different degrees of nail dysplasia.
o The nails, especially those on the thumbs, are typically absent or short and
never reach the free edge of the finger.
o Nail dysplasia, a typical feature, is more severe on the ulnar side than on the
radial side.
o The toenails are rarely affected.
o Other nail abnormalities in patients with nail-patella syndrome include
splitting, longitudinal ridging, koilonychia, poor lunula formation, and

18

discoloration .
In the absence of other nail changes, V-shaped triangular lunulae with a distal peak in
the midline are pathognomonic for nail-patella syndrome.19,20
No treatment is available for the cutaneous findings of nail-patella syndrome (NPS)
Epidermolysis bullosa21:
Nail abnormalities have been reported in all forms of epidermolysis bullosa except the
Weber-Cockayne and the Koebner types and the Mendes da Costa variant.

They are the result of abnormalities of the nail matrix and nail bed associated
with the pathogenic alterations at the dermo-epidermal junction. In addition,
secondary trauma in the areas of epidermal-dermal separation and chronic
inflammation of the nail unit are the possible contributory factors1.
In the lethal junctional type, nail involvement begins early as paronychia-like
periungual lesions and the nails are easily shed. Sometimes, they are absent or
hypoplastic at birth.
Loss of nails is a constant feature of the most severe forms of the recessive
dystrophic type, the mutilating type and the generalized, non-multilating type. Other
nail

abnormalities

are

dystrophy,

onychogryphosis,

pterygium

formation

onychomadesis and onychoschizia.

Darriers diseases
Darrier's disease often involves the nails, which can be a clue for the
diagnosis. The disease more frequently affects fingernails than toenails. Typical signs
are longitudinal red and white streaks with Assuring of the distal margin. All these
signs often coexist in the same nail, bur are not necessarily present in all the affected
nails, which may show other nonspecific signs22

Red streaks, longitudinal erythronychia: These may be single of multiple and

represent an early lesion which. With time, transforms into a white streak.

White streaks. longitudinal leukonychia: These extend from the proximal nail
fold to the distal margin, which may show a small incision and mild
onycholysis due to a subungual hyperkeratotic papule. The width of the
longitudinal white streak varies from 0.1 to a few millimeters.

Other signs of Darrier's disease are not diagnostic and include: splinter hemorrhages,
nail fissuring and fragility, severe nail bed hyperkeratosis, and keratotic papules of the
proximal nail fold.
In some patients, the nails may be grossly thickened and deformed. Secondary
bacterial infection of more severe cases is not unusual.

Diagnostic signs

Red longitudinal streaks (vasodilatation and nail bed epithelial hyperplasia)

White longitudinal streaks (nail bed hyperplasia with multinucleated epithelial

cells)

Distal nail plate incision with subungual papules.

Non-diagnostic signs.

Splinter hemorrhages.

Nail Assuring and fragility.

Massive subungual hyperkeratosis.

Nail Fold keratotic papules.

V shaped nicking is typical of disease.

Red
streak

Clinical
Site of origin
lesion
longitudinal Nail bed

Histological abnormalities
Mild

epithelial

hyperplasia

with

vasodilatation
While

longitudinal

Nail bed

subungal streak

Epithelial

hyperplasia

orthokeratosis
subungal

and

with

parakeratosis

multinucleated

epithelial

giant cells, epithelial nuclear atypia

Wedge shaped distal Distal nail bed and Epithelial
subungal papules
Splinter
hemorrhages

hyponchium
Nail bed dermis

hyperplasia

hyperkeratosis and parakeratosis

Hemorrhage around the blood vessel in
the dermal longitudinal ridges

Proximal nail fold Proximal nail fold Papillary epidermal hyperplasia,

flat keratotic papule

with

and volar epidermis orthokeratosis, suprabasal cleftting

Dyskeratosis congenita 23, 24

Dyskeratosis congenita (DKC), also known as Zirisser-Engman-Cole

syndrome, is a rare, progressive bone marrow failure syndrome characterized by the

triad of reticulated skin hyperpigmentation, nail dystrophy, and oral leukoplakia. DKC
is genetically heterogeneous, with X-linked recessive, autosomal dominant and
autosomal recessive subtypes.

Nail findings
o Nail dystrophy is seen in approximately 90% of patients, with fingernail
involvement often preceding toenail involvement, o Progressive nail
dystrophy begins with ridging and longitudinal splitting. Progressive
atrophy, thinning, pterygium, and distortion eventuate in small, rudimentary,
or absent nails.

Psoriasis 25,26,27
Between 10-50% of patient with psoriasis may have nail involvement in adults and
39% of children. About 10-20% of people who have skin psoriasis also have psoriatic
arthritis, a specific condition in which people have symptoms of both arthritis and
psoriasis of people with psoriatic arthritis, 53-86% have affected nails.
Nail involvement in psoriasis
Proximal germinative matrix

Pitting,

Beau's

lines,

onycholysis,

Distal germinative matrix

leukonychia
Focal oncholysis,

Whole matrix
Nail bed

lunulae, nail plate thinning

Crumbling of the nail plate
oil drop sign onycholysis, subungal

Nail folds

hyperkeratosis, nail discoloration

Loss of cuticle, paronychia

leukonychia,

red

Pitting: It is the most common nail abnormality seen in psoriasis. It results from focal
parakeratosis of the abnormal keratinizing cells of the proximal nail matrix. As the
developing nail plate grows beyond the margin of the proximal nail fold these cells
are lost and leave behind surface indentations that appear as pits. Common in finger
nail than toe nails. Pits are small and deep seated. Occasionally punched out areas are

seen (elkonyxis) sometimes uniform pitting of all nails is seen (thirable nails).
Presence of >20 pits suggests psoriatic etiology. Other causes of nail pitting.
Psoriasis
Reiters disease
Lichen nitidus
Chronic paronychia
After etrinate therapy

Lichen planus
Eczema
Secondary syphilis
Alopecia areata

Salmon patches are circular areas of reddish brown discolorations beneath the nail
plate (oil drop sign) due to focal bed parakeratosis. Splinter hemorrhages occur due to
increased vascularity and fragility of the nail bed dermis.
Onycholysis is common and occurs as distal extension of the salmon patches or may
commence at the distal free edge following disruptions of the onychodermal band. A
separated nail is a good nidus for yeast, dermatophytes and bacteria.
Yellow brown discoloration is due to nail bed disease due to serum glycoprotein
deposition.
Subungal hyperkeratosis results from deposition and collection of cells under the nail
plate that have not undergone desquamation.
Pathophysiology: The pathogenesis of the psoriatic nail disorder is not completely
known. It may be due to a combination of genetic, environmental, and immune
factors. A well known fact is that a familial aggregation of psoriasis exists. Recent
studies have linked psoriasis with certain human leukocyte antigen subtypes (e.g.
Cw6, B13, Bw57, Cw2, Cwlland B27). A T-cell mediated inflammatory process is
being investigated as part of the pathogenesis of psoriasis.
Histopathology: Psoriasis can affect any part of the nail unit. Most changes occur in
the nail plate. Histological findings of nail psoriasis include mild-to-moderate
hyperkeratosis, hypergranulosis, hemorrhage in the corneum layer, papillomatous
epidermal hyperplasia and spongiosis.
Symptoms
Pitting

Sites
Proximal nail matrix

Features
Loss of parakeratotic cells
from surface of nail plate

Beau's lines

Proximal nail matrix

Transverse lines in nails due

to intermittent inflammation

Leukonychia

Midmatrix disease

causing growth arrest lines

Areas of while nail plate due
to foci of parakeratosis within

Subungual
hyperkeratosis

the body of the nail plate

Hyponychium and nail bed Excessive proliferation of the
nail bed and hyponychium.
May lead to

Onycholysis

onycholysis
Nail bed and hyponychium Nail plate separates from its
underlying attachment to nail
bed. Nail plate widens and
may

Nail plate crumbling

Nail bed or nail matrix

detach.

infection may occur

Nail plate weakens due to
disease

Oil drop of Salmon

patch

Nail bed

Secondary

structures
Translucent

of

underlying
yellow-red

discoloration in the nail bed,

resembles drop of oil under
nail plate

Treatment of psoriasis nails28

General medical care, avoid trauma
Topical therapy, calcipotriol ointment twice daily for 5 months
Betamethasone propionate twice daily for 5 months
1% 5 fluorouracil solutions twice daily for 4-6 months
Anthralin in petrolatum once daily for 5 months
Tazarotene gel every night for 6 months.
Cyclosporine solution 0.2ml of 10% oily solution.
Intralesional triamcinoloneacetonide lmg/ml every 3-4 weeks for a total of 4-6
injections.
Puva therapy oral Puva 0.6mg/kg methoxasalen and UVA light 2-3 times a week until
95% clear of lesions. Maintenance once week or less.
Topical Puva - 1% 8 methoxypsoralen and UVA light 2-3 times a week.
Superficial radiotherapy 6-8 treatments with a cumulative dose of 400-600CGY over
a 4 month period followed to 2 months post treatment.
Grenz rays 5 gy of grenz rays given in 10 week courses followed for 6 months post
treatment.
Electron beams weekly 0.75gy for 8 weeks assessed at 3, 6, 12 months post treatment
Systemic therapy
Oral cyclosporine and etrinate Only oral cyclosporine
Psoriatic arthritis. Nail abnormalities are more common. Nail lesions precede joint
involvement. Onycholysis more common in addition to other changes.
Psoriatic onychopachydermoperiostitis: Psoriatic arthropathy with joint and soft
tissue swelling of the digits accompanied by psoriatic nail changes with underlying
bone erosions and perioisteal reaction.

Pustular psoriasis: Pustules develop below the nail plate. In some areas there is
complete disruption of the nail plate. Acrodermatitis continua can be very aggressive
disease and may lead to resorptive osteolysis and loss of fingers and toes.
Lichen planus:29,30,31,32
Nail abnormalities are evident in about 10% of patients with skin or mucosal
lichen planus.29 Nail lichen planus, however, most commonly occurs in the absence of
skin or mucosal involvement.
Nail lichen planus may cause permanent nail destruction if not properly
diagnosed and treated.
Diagnosis of lichen planus of the nails is suggested by thinning, longitudinal
ridging, and Assuring of the nail plate. Pterygium formation is a possible outcome and
indicates nail matrix scarring.30,31
In most patients the disease starts abruptly and the nails become markedly
thinned and longitudinally ridged, opaque, and extremely brittle.
Dorsal nail pterygium describes distal extension has a V-shaped appearance
and often splits the nail plate in two portions. Pterygium occurs where the nail plate is
absent due to nail matrix destruction and widens with progressive scarring of the
matrix.
In addition to these very typical symptoms, nail lichen planus may produce
other nail abnormalities including.

Onycholysis with / without subungual hyperkeratosis.

Yellow nail syndrome-like changes.

Idopathic atrophy of the nails.

Twenty-nail dystrophy.

Pigmentary changes.

Erythema of the lunula.

Nail abnormalities in lichen planus:

Clinical features
Longitudinal ridges

Pathogenesis
Minute focal atrophy of the proximal

Course
Reversible

Pterygium

matrix
Severe destruction of the nail matrix

Permanent

Total nail area atrophy

with scarring
Total destruction of the nail matrix

Permanent

Violaceous lines in the nail

with nail bed involvement

Nail bed disease

Reversible

plate
Subungal hyperkeratosis
Pup tent sign
Vniform thinning of the

Nail bed inflammation

Nail bed disease
Sever diffuse atrophy of nail matrix

Reversible
May be reversible
May be permanent

nail plate
Pterygium unguis is the hallmark of severe nail disease. It is due to focal destruction
of Lie nail matrix.
Causes of Pterygium:
Lichen planus
Leprosy
scarring trauma
I-raft versus host disease

Twenty nail dystrophy

Sarcoidosis
Peripheral vascular disease

Jopecia areata33
Nail abnormalities occur in about 20%- of adults and 50% of children with apecia areata. They are more common in males and in patients with severe alopecia
irsata.33"35 The nail abnormalities may precede or follow the onset of hair loss and
are a . a ^sequence of nail matrix involvement by the disease. Signs that are typical
for alopecia ffsata are geometric pitting and geometric leukonychia.
Trachyonychia (twenty-nail dystrophy) is due to alopecia areata in most cases.
Nail abnormalities may be limited to one nail or involve most of the nails;
Geometric pitting: The nail plate shows multiple, small; superficial pits which
are regularly distributed in a geometric pattern along longitudinal and
transverse lines.

Geometric punctate leukonychia: This is rare but very typical. The nail plate
presents multiple, small white spots, which are geometrically oriented in a
grill pattern36 along longitudinal and transverse lines.

Trachyonychia: The nails are rough due to excessive longitudinal ridging

Alopecia areata also produces nail signs that are not diagnostic, including: Beau's
lines, onychomadesis and erythema of the lunulae:

Onychomadesis and Beau's lines: These rarely develop in coincidence of an

acute attack of alopecia areata. The nail abnormalities involve all or most
nails.

Erythema of the lunulae:37 The Lunula shows mottled erythema. This sign is
most frequently observed in association with trachyonychia.

Histology: spongiotic inflammation of the nail matrix.

Treatment: Intramatricial triamcinolone acetonide.
Endogenous eczema:38
Nail changes are common in patients with hand dermatitis:

Acute eczema produces erythema, edema, and vesiculation of the periungual

tissues. Involvement of the proximal nail fold produces acute paronychia that
may be followed by development of onychomadesis. Beau's lines and irregular
depressions usually appear a few weeks after the episode, as a sign of nail
matrix damage.

Chronic eczema usually affects the proximal nail fold and/or the
hyponychium. Chronic paronychia is the most common presentation with
swelling of the proximal nail fold and loss of the cuticle. The nail plate
frequently shows irregular superficial abnormalities, such as pitting and Beau's
lines resulting from nail matrix damage. Yellow or green discoloration of the
lateral margins of the nail is common and due to secondary bacterial
colonization.

Chronic eczema of the hyponychium presents with subungual hyperkeratosis

and distal onycholysis, usually associated with fingertip scaling. Koilonychia is often
associated.
Patients with atopic dermatitis of the hands frequently present irregular nail
plate surface abnormalities due to eczema.

Treatment consists of topical steroids.

Pemphigus:39,40
Nail involvement in pemphigus vulgaris occurs in up to 22% of patients and is
almost always localized to the fingernails, especially the thumb and the index finger.
Erosive acute paronychia results from acantholysis of the proximal nail fold. It
is often associated with hemorrhagic discoloration of the proximal nail fold with
blood and serum fluid discharge. Pseudopyogenic granuloma of the proximal or
lateral nail fold may be observed. It may be the first symptom of a relapse of the
disease. Beau's lines and onychomadesis may follow acute paronychia41.
Other non-specific nail abnormalities that have been reported in pemphigus
include subungual hemorrhages and onycholysis, trachyonychia, subungual
hyperkeratosis, yellow or brown discoloration, and nail destruction.
Onychomycosis due to dermatophytes appears to be common in patients with
pemphigus, probably as a consequence of therapeutic immunosuppressant.
Nail changes in collagen vascular diseases42-45
Systemic lupus erythematosus: Nail abnormalities are seen in 25% of patients.
Cuticle: ragged or hyperkeratotic, lunulae: red, splinter hemorrhages, pitting, ridging
nail fold erythema, telengicctasia can occur. Nail fold capillary loop density is normal
but the individual capillary appear tortuous or cork screw shaped. In chill blain lupus
there is gross distortion of finger tips and nail plate.
Systemic sclerosis: Pterygium ungium inversus and parrot beak nails are the 2 most
characteristic nail changes. This change is also seen in systemic lupus erythematosus,
neurofibromatosis, and trauma. The parrot beak is over curvature of the free edge of

the nail over a shortened finger as a consequence of atrophy of the soft tissue of the
nail.
Dermatomyositis:
Nail fold erythema, telengiectasias, ragged cuticles, cuticular hemorrhages, pits on
finger nails, half and half nails and anonychia may be seen. Periungal ischemia is
considered a sign of internal malignancy.
Rheumatoid arthritis:
Nail growth decreased. Nail fold telengiectasias and longitudinal ridging with beading
of the nail plate can be seen. Beading of at least 6 fingernails or 4 toe nails is
considered highly specific of an established disease. Rheumatoid nodules can occur at
the free edge of nail.
Sarcoidosis:
Nail changes are seen more in lupus pernio of digits. Thickening, opacity increased
fragility, atrophy, perygium, subungal hyperkeratosis can occur.
Nail changes in systemic disease
Yellow Nail Syndrome46
Yellow nail syndrome is characterized by a triad of yellow nails, lymphedema
and respiratory tract involvement. The cause of the disease is unknown. It is more
common in adults but can also occur in children. The sexes are equally affected.
Nail changes are the most typical manifestations of the disease and are an
absolute requirement for diagnosis. All the nails may be affected, although this is not
universal. The affected nails are thickened and sclerotic (scleronychia) and
excessively curved from side to side. The entire nail plate shows a diffuse yellow to
yellow-green discoloration and appears opaque. 47
The spontaneous clearance of nail abnormalities with resolution of the
systemic changes has been documented.

Treatment with oral and topical vitamin E and with oral zinc supplementation
has been shown to improve nail changes. Interamatrical injections of triamcinolone
may help.48,49
Traumatic nail disorders:50
Onychophagia:
It is a common oral compulsive habit in children and young adults, affecting
around 30% of children between 7 to 10 years and 45% of teenagers. In adults it
occurs due to periods of concentration and focusing. Bitten nails are short and
irregular with 50% of nail bed exposed. Fine spicules may be left at the free edge of
the nails. Nail plate abnormality > onychoschizia) and centrally prounced transverse
ridges (wash board nails) and longitudinal melanonychia may be seen. Periungal
warts are common in nail biters.
Treatment: Behavioral treatments are based in discouraging the habit and replace it
with a more constructive habit.
Pincer nails (Trumpet nails):
It is characterized by overall transverse over curvature that is most prominent in the
midline and distally. The nail plate assumes a conical shape and rises above the nail
and in extreme cases a tunnel is formed. The lateral border of the nail tightens round
the soft tissue giving the latter a pinched appearance. It is seen those wearing ill fitting
shoes, psoriasis, tinea ungium, beta blockers use. Paronychial infections may be more
frequent with this type of nail irregularity.
Treatment: Restoration of the normal contour and shape of the nail plate is achieved
with the aid of dermal grafts under the lateral edges of the nail bed.
Habit tic deformity:
Habit-tic deformity, a relatively common nail disorder. It is caused by the
conscious or unconscious rubbing and picking of the proximal nail fold and cuticle
area. Habit-tic deformity is most often found on the thumb of the dominant hand,
which is being rubbed by the index or middle finger of that same hand. Other fingers
may become involved, especially during times of stress. The resulting deformity is a

washboard nail which consists of depression down the center with numerous
horizontal ridges extending across the nail. While habit-tic deformity is considered to
be a compulsive disorder and medications such as selective serotonin reuptake
inhibitors may be used.
Ingrowing toe nail
The soft tissue at the sides of the nail (lat nail fold) is penetrated by the edge of the
nail plate resulting in pain, sepsis and later formation of granulation tissue. Most
common cause in ill fitting footwear. Ingrowth toenails are common in adults but
uncommon in children and infants. They are more common in men than in women.
Teenagers and young adults are most at risk. Any toenail can become ingrown, but the
condition is usually found in the big toe.
Signs and symptoms:
Pain and tenderness in your toe along one or both sides of the nail
Redness around your toenail
Swelling of your toe around the nail
Infection of the tissue around your toenail
Common causes include:
Wearing shoes that crowd toenails.
Cutting toenails too short or not straight across.
Injury to toenail.
Unusually curved toenails.
Thickening of toenails.
Treatment: If no acute infection is found, conservative treatment is recommended.
This consists of warm soaks, proper shoes, and frequent cleaning of the nail.
Excessive granulation tissue is cauterized with silver nitrate. If an infection is present,
then surgical removal of either part of the nail or the whole nail and drainage of the
abscess will be needed. Removal of the nail with phenolization of the relevant part of
matrix can be done. C02 laser has also been used.
Median nail dystrophy of Heller (Dystrophia unguis mediana canaliformis,
Solenonychia)1

In this condition there is a single longitudinal defect in the nail. This condition is
uncommon and is of unknown cause. Usually it affects the thumbnails. The defect
starts at the cuticle and grows out to the distal edge. Extending laterally from the
center are often a few cracks projecting towards but not quite reaching the free edge
of the nail resembling an inverted fir tree.
Onychogryposis38
Onychogryphosis is an exaggerated enlargement of the nail plate. In most
often only involves the great toenails. However, it may occur on the fingernails.
Onychogryphosis is common in older individuals. This condition can also be observed
in individuals who are homeless, have senile dementia, or are infirm.51, 52
The primary predisposing factor for onychogryphosis is inadequate foot and
nail care.
Secondary factors that can influence the development of onychogryphosis
include continuous pressure and friction on the toenails due to improper footwear, a
previous history of nail trauma, hypertrophy of the nail bed, biomechanical bony
abnormalities such as hallux valgus, impairment of the vascular and neuronal system,
and onychomycosis.53
Clinically, the shape of onychogryphotic nails appears 'oyster like' or 'ram's
horn-like'. The nail plate is typically uneven, thickened, and brown to opaque.
Multiple transverse striations are often present. In addition, the underlying nail bed
may also be hypertrophic.54
Treatment: Definitive therapy involves nail avulsion and matrix ablation.
Skier's toe footballer's toe.
A subungual hematoma may form from chronic repetitive trauma to the nail,
typically minor shearing damage as occurs when a skier's toe repeatedly presses
against the ski boot or when a football is kicked. It is often bilateral and usually
affects only each hallux.

No treatment is needed.
Splinter hematoma
Splinter hemorrhages are formed by the extravasation of blood from the
longitudinally oriented vessels of the nail bed. The blood attaches itself to the
underlying nail plate and moves distally.
The splinter hemorrhages occasionally appear to remain stationary, probably
because of attachment to the nail bed rather than to the plate.
Splinter hemorrhages can be caused by physical factors, including trauma,
drugs, dermatologic diseases, systemic diseases, and idiopathic conditions, among
others. Trauma is by far the most common cause.55'56At times, certain presentations
of splinter hemorrhages should make one consider a systemic cause, particularly
bacterial endocarditis57. Their simultaneous appearance in multiple nails is more
frequently associated with systemic disease. Also, their occurrence closer to the lunula
as opposed to the distal nail plate seems to be more directly correlated with systemic
disease.55,56
Miscellaneous information about splinter hemorrhages:
1.

Splinter hemorrhages are more common in the elderly, are more common in
Black people, and are located distally.

58,59

When found in women, splinter

hemorrhages are more likely to indicate systemic disease59.

2.

In one study, the left hand was involved greater than three times more
frequently than the right hand in patients with single hemorrhages; the left
thumb was the digit most frequently involved.60

3.

In patients with multiple hemorrhages, more occurred on the left hand than the
right hand. The thumb was the most frequently involved digit, followed by the
left index finger and the left thumb.60

4.

In one study, peritoneal dialysis was the single most frequently encountered
factor in patients with splinter hemorrhages.61

5.

Biopsy of splinter hemorrhages that are associated with trichinosis may reveal
the organism.

6.

In trichinosis, splinter hemorrhages may be oriented transversely instead of

longitudinally.

7.

Splinter hemorrhages have been described histologically.

It is the commonest nail injury. If injury is under the exposed nail the bleeding will be
immediately apparent but if the injury is below the dorsal nail fold the injury may not
be visible for 2/3 days and will move forward with the growth of the nail.
Haemorrhage in the matrix is incorporated in the nail plate. While one distal to the
lunula remains subcuticular unless removed. The possibility of underlying fracture
must consider for larger hematoma.
Types, effect and therapy of acute injury
Type
Effect
1
Small hematoma with small break in

Therapy
Fenestration of nail

nail bed
Large hematoma with significant nail

Remove nail

3
4
5

bed injury
Large hematoma nail plate displaced
Severe crush injury
Amputation of tip of digit

Requires resorbable sutures

Avulsion
If tip can be retrieved it should be
used as a graft or autologous graft

Treatment if more than 25% of the visible nail is affected the nail plate should be
removed. Reduction of pressure is carried out by making a small puncture hole
through nail plate with a hot cautery point.
Pits and ridges: are caused due to trauma to matrix. The associated injuries are usually
the severe and damage to the nail is not appreciated for months.

Tumors of the nail 62, 63

Sungual exostosis: 62
It is benign bony outgrowth of the terminal phalanx usually found on the great toe.
Subungual exostosis is a variant of osteochondroma. The male: female ratio of

reported case is 1:2. Average patients are in their twenties, but many teenagers are
affected.
Cutical: The dorsal, medial aspect of the hallux is the most common site. The lesion
appears a pinkish nodule under the free end of the nail plate. Elevation and dystrophy
of overlying nail plate may occur.
Treatment is surgical.
Ganglion cyst64
This entity is highly connected with osteoarthritis, especially in women. Location on
the fingers is most common; involvement of the toes is possible. Anatomically, it
represents the collection of gelatinous material in a cavity within connective tissue, in
connection with the distal interphalangeal joint (DIJ) and lacking epithelial lining.

Located on the proximal nail fold, half way between the DIJ and the cuticle, it
presents as a skin-colored. Smooth surfaced, translucent, dome-shaped
swelling, with a greater or lesser tendency to spontaneous discharge.

Located more distally beneath the proximal nail fold, it faces a longitudinal
groove on the nail plate due to compression of the cyst on the matrix. This
gutter may exhibit transverse grooves of various depths acknowledging for the
successive swelling and discharge episodes of the cyst.

Location beneath the nail matrix is unusual and produces several nail
dystrophies such as red-blue lunula, proximal lamellar splitting, nail fissure or
even pincer nail.

Treatment

Many treatments have been proposed for the condition but best results are
obtained with surgery.

For patients not willing to undergo surgery two other simple techniques are
recommended:

Injection of 0.2 ML sclerosing agents such as 1% tetradecyl sodium after

puncture and expression of the jelly-like65

Repeated puncture of the cyst followed by compressive dressings for several

weeks may sometimes be helpful.

Glomus tumor38
Glomus tumor can occur anywhere on the body but up to 75% are found in the
hand, and the vast majority is located on the finger tips. It arises from the
neuromyoarterial glomus cells of the nail bed dermis. Amazingly, this condition is
encountered in females around 45 years old in almost 90% of cases. The triad of pain,
cold intolerance, and pin-point tenderness is highly suggestive of the condition.
Subjective symptoms typically exceed clinical sings. Pain is the leading symptom; it
may be excruciating and irradiating. Pain is the leading symptom; it may be
excruciating and irradiating proximally.
MRI is the best imaging technique for demonstrating the tumor.
TREATMENT
Treatment is the surgical removal of the tumor.
Pyogenic granuloma38:
Pyogenic granuloma is a benign vascular tumor, mostly seen in the early
decades, usually presenting as a rapidly evolving, solitary, sessile or polypoid vascular
nodule prone to ulceration or hemorrhage. Its precise pathogenesis remains unclear.
Location on the nail apparatus is a common finding: Pyogenic granuloma formation is
most commonly due to trauma on the fingernails; the nail-plate-lateral- sulcus
interaction is responsible for their arising on the toenails.
Several systemic drugs have been responsible for pyogenic granulomas in the
lateral nail sulcus: indinavir, retinoids, cyclosporine. lamivudine, capecitabine. Cast
immobilization and friction from footwear have been reported as causing pyogenic
granulomas .

Treatment
Treatment consists in curettage or C02 laser vaporization of the lesion under
local anesthesia. In growing toenail resulting from improper nail trimming, curettage
must be completed by the resection of the offending spur.
Fibrokeratomas38:
The acquired digital fibrokeratoma (FK) is a benign fibroepithelial growth of
unknown origin. Localization in the nail apparatus is common. FKs are usually
unique, more common in men over 50 years old and do not resolve spontaneously.
Trauma has often been considered as a trigger of this overgrowth but some reports
suggest a hamartomatous origin. They are pinkish elongated tumors often associated
with a hyperkeratotic tip.
Clinical features depend on the location of the tumor:

Developed from the ventral aspect of the proximal nail fold it causes a
longitudinal depression on the nail plate due to compression on the underlying
matrix. The tumor may be hardly visible as it may be covered by the proximal
nail fold. Otherwise it rests within the gutter.

Originating from the dermis beneath the nail matrix it may be responsible for
permanent nail dystrophy (even after excision of the tumor).

Originating from the nail bed it pushes up the nail plate creating a prominent
ridge. Subungual filamentous tumors are probably a very thin variant of that
type

Treatment is surgical removal.

Ony cho matr icoma:66
Onychomatricoma is a benign tumor of the nail matrix first described by
Baran andKintin 1992.
Onychomatricoma affects most commonly the fingernails of middle-aged
individuals and has never been reported in children. The nail presents a longitudinal

band of thickening or a diffuse thickening of the nail plate, which is transversally

over-curved. The affected nail plate is white-yellow in color and often shows
longitudinal ridging and proximal splinter hemorrhages.
At the frontal view the tumor has a very characteristic picture because the nail
plate shows multiple holes in its thickened free margin. These correspond to
longitudinal hollows that contain the digitating tumor, which perforate the nail plate.
The tumor growth is quite slow and usually painless.
Histologically, the tumor consists of multiple fibroepithelial projections that
perforate the nail plate. The tumor epithelium resembles the matrix epithelium with
absence of a granular layer.
Treatment
Surgical excision is the treatment of choice. The gross anatomy of the nail
plate after excision suggests the diagnosis, showing the multiple cavities that perforate
the nail plate.
Squamous cell carcinoma
Squamous cell carcinoma is the most common malignant tumor of the nail and
usually affects the fingernails of middle-aged males.
Predisposing factors include chronic radio dermatitis and HPV infection. HIVpositive patients are especially susceptible to developing HPV associated squamous
cell carcinoma and possible transmission of HPV from genital lesions is suggested by
several studies67.
The tumor usually presents as a slow-growing periungual or subungual nodule
that ulcerates and bleeds.
Paronychia is commonly associated. Subungual lesions produce onycholysis
and nail plate destruction.
Less commonly, squamous cell carcinomas appear as verrucous hyperkeratotic
lesions that look like a viral wart.
Treatment68:-

Mohs' surgery is the treatment of choice, especially for periungual and

subungual squamous cell carcinoma without bone involvement. Where the cure rate
approaches 96%.
Amputation is necessary when the bone is affected.
Malignant melanoma:69
Subungual melanoma is a specific type of melanoma that occurs under the nail
bed more commonly in dark-skinned people. Subungual melanoma is characterized
by a dark colored stripe that runs along the length of the nail plate, not across the nail.
Signs that are concerning for subungual melanoma and should be evaluated include:

Hutchinson's Sign - Spread of pigmentation into the nail folds

Pigmentation in single digit

Occurs at age 50 or older

Occurs in the thumb, index finger or great toe

Blurred borders

It can also present as a chronic paronychia, granulation tissue resembling pyogenic

granuloma without the added pigmented band or warty thickening of the nail bed and
shedding of the nail. Treatment consists of amputation of the digit with removal of
regional nodes.
Infections of the nail: Acute paronchia 70, 71
Etiology and pathogenesis: It is the term used for inflammation of the
proximal and lateral nail folds. Bacterial infection may occur, usually due to
staphylococcus aureus or streptococci. Anaerobes or Candida may also be found. Risk
factors include trauma, manipulation, and oral isotretinoin treatment.
Clinical: An acutely tender, red, periungual swelling occurs in acute paronychia.
Pustules may be visible below the cuticle.
Treatment:72,73

The area should be drained if fluctuant. Soaking should be prescribed if the

area is crusted or already draining. Oral antibiotics should be given.
Chronic Paronychia
Etiology and pathogenesis
The etiology is frequently multifactorial and includes the following.
1) Physical damage and wet work-including manicures, pushing back the cuticle,
frequent contact with water (e.g. for housewives and bartenders), and saliva.
2) Chronic colonization by saprophytic fungi, particularly Candida spp Chronic
bacterial infection of the paronychial area - organisms that may be found
include Proteus, Klebsiella, Enterococcus, staphylococci, and Pseudomonas
(often multiple e.g. two to four, organisms are found).
3) Eczemas
Clinical: The condition begins as slight swelling at the base of 1 or more nails which
is tender but less than that in acute paronychia. The cuticle is lost and pus may form
below the nail fold. Inflammation adjacent to the matrix disturbs the nail growth
resulting in irregular transverse ridges and other surface irregularities and
discoloration.
Treatment: Eczema in the periungual area should be treated with a topical steroid,
together with allergen avoidance where proven relevant. Whatever the cause, the area
should be kept meticulously dry, which may require use of gloves or altering hobbies
or activities. If wet work is unavoidable, a greasy emollient may give some protection,
but prolonged occlusion of the space under the nail fold should be avoided. Topical
combination of steroids and antimicrobial is useful. Surgical removal of the proximal
nail fold and adjacent part of the lateral nail fold may cure recalcitrant cases.
Pseudomonas colonization: Pseudomonas often grows in the moist environment
created by an onycholytic nail green or black discoloration of the nail is seen when
there is Pseudomonas colonization. Rarely, the green color of Pseudomonas may
extend on to the skin.
Herpetic whitlow:

Herpetic whitlow is an intense painful infection of the hand involving 1 or more

fingers that typically affects the terminal phalanx. Herpes simplex virus 1 (HSV-1) is
the cause in approximately 60% of cases of herpetic whitlow, and herpes simplex
virus 2 (HSV-2) is the cause in the remaining 40%. In children the primary source of
infection is the orofacial area, and it is commonly inferred that the virus (in this case
HSV-1) is transferred by the chewing or sucking of fingers or thumbs. In adults it is
more common for the primary source to be the genital region, with a corresponding
preponderance of HSV-2. It is also seen in adult health care workers such as dentist
because of increased exposure to the herpes virus.
Patients present with complaints of pain and swelling of a finger, typically with
characteristic vesicular lesions. The most commonly involved digits are the thumb
and index fingers. Although it is self-limited illness, topical antiviral, particularly
topical acyclovir, have been shown to be effective in decreasing the duration of
symptoms.
Fungal infection
The term 'onychomycosis' refers to fungal infection of one or more of the components
of the nail unit and can be caused by dermatophytes, yeasts, or nondermatophyte
molds. The term 'tinea unguium' is generally applied to dermatophytosis of the nail
unit. There are four patterns of fungal invasion into the nail unit: distal lateral
subungual onychomycosis (DLSO), white superficial onychomycosis (WSO),
proximal subungual onychomycosis (PSO), and Candida onychomycosis.
Onychomycosis is a challenging disease for patients and physicians, despite recent
advances. Diagnosis remains difficult and often cumbersome, and treatment is still
costly. While many have considered this disease a cosmetic problem, patients often
complain of pain and discomfort and are often limited in their activities.
The prevalence is higher in patients with HIV, in whom it has been reported to be
approximately 25%.74 Studies in the UK75, Spain76, and Finland found an overall
prevalence of 3%, 1.7%, and 8.4%, respectively. It is probably the most common nail
disorder, accounting for up to 50% of all nail diseases.

Dermatophytes cause the majority of nail infections. In a large study by

Summerbell and others of 2662 nail-invading infective agents, dermatophytes were
isolated in 91 % of cases, Candida albicans in 5.5%, and various nondermatophyte
molds in 3%. In a more recent study of 217 cases of onychomycosis, dermatophytes,
nondermartophytes, and yeasts were cultured in approximately 60%, 20%, and 20%
of cases, respectively.77 Because the clinical manifestations may be identical, a fungal
culture is essential in determining the infective agent. Not all patients with dystrophic
nails have onychomycosis and a thorough understanding of the disease process is
required to establish a proper diagnosis and make informed decisions regarding
therapy.
TINEA UNGUIUM
It is not surprising that dermatophyte fungi are the most common cause of
onychomycosis because they are keratinolytic pathogens and invade normal keratin of
the skin, hair, and nail. The most common dermatophyte nail pathogens are
Trichophyton rubrum and T. mentagrophytes, which are also the most common causes
of tinea pedis. The various causative agents of tinea unguium are listed below:
Dermatophyte :

Trichophyton
rubrum

Trichophyton
mentagrophytes

Epidermophyton
floccosum

Nondermatophyte:
Acremonium

Aspergillus species

Cladosporium carrionii

Fusarium species

Onycochola Canadensis

Scopulariopsis brevicaulis

Scytalidium dimidiatum\

Scytalidiuni hyalinum

Yeasts:
Candida
albicans

Toenails are about 25 times more likely than fingernails to be infected, and
dermatophyte fingernail involvement rarely occurs without toenail involvement. The
longest toe either the first or the second, which bears the brunt of pressure and trauma
from footwear, is particularly susceptible to invasion although multiple nails are
typically infected. Some authors believe that eliminating the instigating facto** may

often result in spontaneous resolution.78 Premenopausal females with no predisposing

factors are less frequently affected than men of the same age group79, suggesting that
estrogen may offer a protective effect. Although prepubertal children are rarely
affected with this disease, possibly because of the protective element of faster nail
growth in this age group.80, 81
Distal Subungual Infection
The most common variety of onychomycosis, distal lateral subungual
onychomycosis (DLSO), starts as an infection of the cornified layer of the
hyponychium and distal or lateral nail bed. It is best described as 'nail bed
dermatophytosis', and is most commonly caused by T. rubrum and T. mentagrophytes.
The first clinical signs of infection include the following: discrete, distal (or lateral)
focus of onycholysis, yellow, brown discoloration, and hyperkeratosis of the nail bed.
A mild inflammatory reaction occurs in the hyponychium and nail bed, resulting in
further hyperkeratosis with accumulation of subungual debris, discoloration, and
onycholysis.
White Superficial Onychomycosis
(WSO; Leukonychia Trichophytica)
WSO, a less common variety, is a distinctive pattern in which the nail plate is
the primary site of invasion. The infection then proceeds to include the nail bed and
hyponychium. It is most frequently seen in toenails and is primarily caused by T.
mentagrophytes, which possesses enzymes that allow it to digest and invade the nail
plate directly.
The infection manifests as speckled or punctate porcelain-white lesions
randomly distributed along the surface of the nail plate, gradually coalescing to
involve the whole surface.82

Proximal Subungual Onychomycosis (PSO)

PSO, a rarely seen pattern that affects fingernails and toenails equally, is
primarily caused by T. rubrum; T. mentagrophytes, T. schoenleinii, T. tonsurans; and

T. megninii have also been reported to cause the condition. The fungus initially
invades the stratum corneum of the proximal nail fold and subsequently penetrates the
newly formed nail plate. The clinical result is a white discoloration under the
proximal nail plate in the area of the lunula; the distal nail unit remains normal. As
opposed to WSO the nail plate is intact. Subungual hyperkeratosis, onychomadesis
and eventual destruction and shedding of the entire nail plate may occur in advanced
disease. Because it is infrequent, some authors believe that a preceding episode of
trauma is a prerequisite for it to occur in immunocompetent patients.
Proximal white subungual onychomyscosis (PWSO) has been described with
increasing frequency in patients with acquired immunodeficiency syndrome (AIDS).
In fact, this rare form of onychomycosis was seldom encountered before AIDS
became prevalent.83
T. rubrum is the most common pathogen.
OTHER FUNGAL INFECTIONS
Non-dermatophytic molds cause 1.5-6% of onychomycosis. In the study by
Summerbell and colleagues, non-dermatophyte molds constituted up to 3.3% of the
organisms cultured from nail infections.84
Investigations:
1) Direct microscopy
2) A 20% potassium hydroxide (KOH) preparation in chlorazole black-E(CBE) is
a useful screening test to rule out the presence of fungi.
In CBE, specimen should be obtained, from the nail bed by curettage. It should be
obtained at a site most proximal to the cuticle, where the concentration of hyphae is
greatest. In PSO, the overlying nail plate must initially be pared with a number-15
blade. Then, a sample of the proximal nail-bed may be taken. A number -15 blades
may also be used to remove a specimen from the nail surface in WSO. Specimens
suspected of candidal OM should be taken from the affected nail bed closest to the
proximal and latheral edges. CBE is tris-azo dye selective for chitin. It stains fungal
element green- blue against black gray background making visibility of hyphae
prominent and easy.85

Culture
Direct microscopy cannot identify the specific pathogen involved in
Onychomycosis. A fungal culture must be used to identify the species of organism.
Nondermatophyte molds may be resistant to the conventional therapy used for the
more common dermatophytes. Therefore, 2 types of growth medium should be used,
one with cycloheximide (dermatophyte test medium [DTM], Mycosel, or Mycobiotic)
to select for dermatophytes and one without cycloheximide (Sabouraud glucose agar.
Littman oxygall medium, or inhibitory mold agar) to isolate yeasts and
nondermatophyte molds. Cultures should be obtained from pulverized nail scrapping
or clipping while the patients has abstained from antifungal medication for at least 2
weeks.
Treatment is with oral antifungals like griseofiilvin, fluconazole, itraconazole,
terbinafine.
Scabies:
Nail changes are found in crusted scabies. The subungal material contains
abundant mites and may be a source of dissemination of disease.
Syphilis:
Primary Syphilis: Chancre can present as periungal erosion or ulcer.
Secondary syphilis: Nails are brittle and tend to split (onyxis craquele). Linear pitting,
elkonysis, onychlysis, beaus lines can also be seen.
Tertiary syphilis: Amber colored nails can sometime be seen.
Periungal warts(Subungual warts)38
These are the most common tumor involving the nail unit. They are caused by
various human papilloma virus. They present as hyperkeratotic papules showing a
rough surface. Most commonly they are located on the nail folds (proximal and
lateral) but sometimes extend to the nail bed with associated onycholysis. Fissuring of
the hyperkeratosis may be painful. Distortion of the nail plate is exceptional. Nail

biting enhances spreading on other fingernails. Warts are very common and hard to
treat in the immunosuppressed, particularly in organ-transplant recipients.
The most significant lesion from which warts need to be distinguished is
epidermoid carcinoma (Bowen's disease).
Wide range of therapies is available, including keratolytics combined with
abrasion, cryosurgery, bleomycin puncture, imiquimod, laser therapy, interferon and
immunotherapy using sensitization to diphencyprone, naturally acquired immune
sensitivity to pathogens.
Longitudinal melanonychia
Longitudinal melanonychia, brown-pigmented longitudinal streaks of the nail,
may be a normal variant in darker-skin individuals or they may actually be nevi. Less
commonly, they may represent Addison's disease, acanthosis nigricans, Peutz-Jeghers
syndrome, trauma, subungual hemorrhage and fungal infection, or even an underlying
melanoma, especially when they occur on the thumb (most common site for
melanoma of the nail unit). Black discoloration of the proximal nail fold at the base of
the pigmented streak (Hutchinson's sign) is an ominous sign for melanoma.
Longitudinal melanonychia in one nail without an obvious explanation warrants a
biopsy of the nail matrix.
Nail changes following systemic drug use1
Systemic drugs can produce nail abnormalities.asymtomatic growth rate changes &
pigment abnormalities are the most common changes . the nail changes observed with
commonly used drugs are as follows.

Possible nail abnormalities

Therapeutic agents
Beta-blockers

Possible Nails abnormalities

Thickening and discoloration of nail plates, nail pits,

Calcium Channel
blockers
Captopril
Losartan
Cancer chemotherapy

Beau's lines, pterygium inversus unguis

Nail dystrophy
Onycholysis
Chromonychia, clubbing (reversible)
Diffuse hyperpigmentation of nail plates. Longitudinal and
transverse melanonychia, transverse leukonychia. Mee's
lines. Transverse loss of nail plate. Beau's lines.
Onycholysis, nail shedding subungual hyperkeratosis,

Carbamazepine
Phenytoin (use in

paronychia. Nail dystrophy, slow growth.

Onychomadesis, longitudinal melanonychia
Hypoplasia, anonychia or nail dystrophy in the newborn

pregnancy)
Chloroquine
Mepacrine

Blue purple transverse nail bed pigmentation

Brownish discoloration of the nail beds, pitting, ridging or

Quinine
AZT

shedding of the nails

Photo-onycholysis
Blue lunulae, diffuse hyper pigmentation of the nail plates,
longitudinal or transverse melanonychia, paronychia, slow

Lamivudine

growth
Paronychia,

Psoralens

melanonychia
Photo-onycholysis,
longitudinal

pseudopyogenic
pain,

granuloma,
splinter

melanonychia,

proximal

longitudinal
hemorrhages,
nail

plat

Oral contraceptives

pigmentation. Beau's lines, subungual hematomas

Increased nail growth, nail loss, photo-onycholysis in

Vitamin A toxicity
Retinoids

patients of porphyria cutanea tarda

Brittle nails, nail dystrophy
Brittle nails, thinning, softening, shedding, Beau's lines.
Onychoschizia, onychomadesis, elkonyxis, medial nail
dystrophy, chronic

(sometimes

painful),

paronychia,

Aspirin
Ibuprofen
Cyclosporine
Sirolimus
EGFR inhibitors

transverse leukonychia, 'curly' nails

Purpura of the nail bed
Longitudinal melanonychia
Transverse leukonychia, nail pitting, increased nail growth
'Chronic onychopathy', periungual infection
PRIDE syndrome (paronychia), pyogenic granuloma-like

(imatinib, sorafenib,

lesions of the nail folds

sunitinib, gefitinib,
cetuximb)

Thiazide diuretics

Onycholysis

Therapeutic agents
Penicillamine

Possible nail abnormalities

Absent lunulae, onychoschizia, longitudinal ridges,

Salbutamol
Phenolphthalein
Cephalexin
Cloxacillin
Chloramphenicol
Tetracyclines

elkonyxis. Beau's lines, yellow nail syndrome

Periungual erythema
Nail plate ridges, blue lunulae
Periungual inflammation, nail shedding
Nail shedding
Onycholysis, photo-onycholysis
Photo-onycholysis, splinter hemorrhages, painful nails, nail

Fluoroquinolones
Clofazimine

pigmentation (with minocycline)

Photo-onycholysis, Beau's lines, subungual hemorrhages
Brownish discoloration of the nail plates (reversible),

Itraconazole
Fluconazole
Ketoconazole
Sulfonamide

subungual hyperkeratosis, onycholysis

Accelerated nail growth, longitudinal beading
Increased nail growth, longitudinal melanonychia
Longitudinal pigmented bands, splinter hemorrhages
Onycholysis. Beau's lines, partial leukonychia, slow

(including

growth, fixed drug eruption of periungual tissues

dapsone)
hypersensitivity
Nail changes secondary to systemic chemical poisoning
Amiline
Arsenic

Blue-violet nails
Mees' lines, Beau's lines, onychomadesis, longitudinal
brown

bands,

diffuse

melanonychia,

subungual

Gold
Carbon monoxide
Fluorine
Lead
Mercury
Paraquat

hyperkeratosis
Nail pigmentation, fragility, onycholysis
Cherry red nail beds and lunulae, leukonychia
Longitudinal brown bands
Onychomadesis, onychalgia, leukonychia
Ridging, fragility, dark discoloration of the nail plates
Greenish-black nails, white bands, brown bands, softening

Selenium
Silver
Thallium

of nail plates, nail loss

Horizontal white streaks; purple nails, nail shedding
Blue lunulae, slate-blue discoloration of proximal nail beds
Onychorrhexis, Mees' lines

CLASSIFICATION 2
Abnormalities of shape
Clubbing:
Since Hippocrates first described digital clubbing in patients with empyema, digital
clubbing has been associated with various underlying pulmonary, cardiovascular,
neoplastic, infectious, hepatobiliary, mediastinal, endocrine, and gastrointestinal
diseases. Finger clubbing also may occur, without evident underlying disease, as an
idiopathic form or as a Mendelian dominant trait. Clubbing is a clinically descriptive
term, referring to 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.
Digital clubbing is classified into primary (i.e., idiopathic, hereditary) and secondary
forms. Digital clubbing may be symmetric bilaterally, or it may be unilateral or
involve a single digit. Anatomic considerations, such as the classic measurement of
the Lovibond angle or the more recently derived index of nail curvature by Goyal et
al.86
Usually can be identified on simple physical examination and can be used to identify
digital clubbing and to monitor this dynamic process objectively Although clubbing is
a common physical finding in many underlying pathological processes, surprisingly,
the mechanism of clubbing remains unclear. Different pathological processes may
follow different pathways to a common end. Many studies have shown increased
blood flow in the clubbed portion of the finger. Whether the vasodilatation results
from a circulating or local vasodilator, neural mechanism, response to hypoxemia,
genetic predisposition, or a combination of these or other mediators is not agreed on
currently.87

Clubbing is a clinical finding characterized by bulbous fusiform enlargement

of the distal portion of a digit When the profile of the distal digit is viewed, the
angle made by the proximal nail fold and nail plate (Lovibond angle) typically
is less than or equal to 160. In clubbing, the angle flattens out and increases
as the severity of the clubbing increases. If the angle is greater than 180,

definitive clubbing exists. An angle between 160-180 falls in a gray area and
may indicate early stages of clubbing or a pseudoclubbing phenomenon.

Individuals without clubbing display a diamond-shaped window at the base of

the nail beds when the dorsum of 2 fingers from the opposite hands are
opposed. The distal angle between the 2 opposed nails should be minimal. In
individuals with digital clubbing, the diamond window is obliterated and the
distal angle between the nails increases with increasing severity of clubbing.

Koilonychia (koilos - hollow, onyx-nail) 88 Spoon-shaped nails are not uncommon.

Their relationship to systemic disease is at times relatively clear, but most frequently
nebulous. Classically, when koilonychias is mentioned, one's thoughts turn to iron
deficiency anemia or Plummer-Vinson syndrome. This is not; however, one of the
more common presentation occurs in babies as a traumatic response to rigid shoes that
are perhaps too tight. A drop of water placed on a spoon nail will not roll off. The
spooning is best viewed from the side.
The exact cause of koilonychias is at best elusive, but several hypotheses have been
given. Stone suggested that angulation of the nail matrix secondary to connective
tissue changes is the cause: 'Spooning of the nail occurs when the distal matrix is
relatively low compared to the proximal matrix and vice-versa for clubbing. 89 Jalili
and Al-Kassaf90 found that the cystine content was somewhat low in the nails of
patients with anemia and very low when koilonychia was present. They thus
concluded that a deficiency of sulfur-containing amino acids played a role in the
pathogenesis of koilonychia.90
Most publications categorize spoon nails into their major groups: idiopathic,
hereditary, and acquired. We believe that acquired is the largest group. Trauma,
dermatologic diseases such as psoriasis and fungal infection, and distal ischemia as in
Raynaud's phenomenon seem to be the most common offenders.
Koilonychia has also been associated with an upper gastrointestinal tract carcinoma. 91
Koilonychia can be inherited in a dominant manner with a high degree of
penetrance.92 This group is probably the least commonly encountered.

Stone compiled an extensive list of possible diseases associated with koilonychias.

Some additions include alopecia areata,93 carpal tunnel syndrome,94 and scurvy.
Abnormalities of nail surface
Lamellar dystrophy (onychoschizia)
The distal free edge of the nail splits horizontally into layers. This is specially seen in
woman who soaks their hands repeatedly in water, psoriasis, Darriers disease, lichen
planus, retinoid use.
Brittle nails (Onychorrhexis)95, 96
Roughness and irregularity of the distal nail plate in an elderly patient is characteristic
of this condition. Women are more commonly affected than men, and wet working
conditions may aggravate the symptoms. Those factors that dry out the nail, including
excessive wetting and drying, should be avoided. Soaking the nails for lOmin a day,
often best done at night, and applying petrolatum afterward may be tried. Biotin (.e.g.
2500mg/day) has been reported to be effective.
Trachyonychia 38
Trachyonychia describes an abnormality of the nail plate surface that is rough due to
excessive longitudinal riding. The condition most commonly affects most or all nails
and is idiopathic or associated with alopecia aerate. Idiopathic trachyonychia is
uncommon and almost exclusively seen in children.
Trachyonychia associated with alopecia areata occurs in up to 12% of children
affected by the disease, especially those with alopecia totalis or alopecia universalis.
This explains why the presence of trachyonychia is considered a negative prognostic
factor in patients with alopecia areata.
The nails are thin, opaque and lusterless and give the impression of having been
sandpapered in a longitudinal direction (vertically). Fragility of the superficial nail
plate may be severe. Koilonychia is occasionally associated. Hyperkeratosis of the
cuticle is often present.

Histologically nail matrix shows a spongiotic inflammation with a fairly dense

mononuclear inflammatory infiltrate and occasionally a lichen planus or psoriasiform
pathology. It is either idiopathic or associated with lichen planus eczema or psoriasis,
icthyosis vulgaris, alopecia areata, primary biliary cirrhosis.
Histology: Hypergranulosis with marked spongiosis can be seen. Occasional saw
toothing of the rete ridges and colloidal bodies seen.
Treatment:

Potent topical steroids / intralesional steroids

Oral steroids
Intramuscular triamcinolone acetonide
Oral cyclosporine or azathioprine
Ulcerative lichen planus: grafting of the nail bed.

Abnormalities of nail color

White Nails (Leukonychia)1 There are several subtypes of leukonychia (white nails)
true leukonvchia (pathology originates in the matrix and emerges in the nail plate),
apparent leukonychia (pathology is in the nail bed), and pseudoleukonychia (nail plate
pathology is exogenous, e.g. onychomycosis).97Leukonychia associated with
systemic disease is usually true leukonychia or apparent leukonychi:..
True Leukonychia
True leukonychia can be total, subtotal, or partial (transverse punctuate, longitudinal
most commonly). Total or subtotal leukonychia can be inherited, sporadic or
associated with systemic illness. Partial leukonychia is especially common in the
transverse and punctate forms and is most commonly caused by trauma to the matrix
from overly aggressive manicuring of the proximal nail fold area. There are however,
numerous associations with drugs or systemic illness.98
Histologically, parakeratosis and large, immature keratohyaline granules have been
described in the areas of leukonychia.99
However, electron microscopic findings suggest that clear lipid vacuoles may actually
be the cause of leukonychia.

Mees lines are transverse types of true leukonychia associated with systemic disease.
Arsenic intoxication was classically believed to be the major cause of Mees lines. It is
now well know that numerous severe systemic insults may be the stimuli to initiate
the abnormality. 100 It has been said that Mees lines that occur as a result of arsenic
poisoning are due to actual deposition of arsenic in the nail plate.

101

One may

approximate the time of onset of systemic illness by measuring the distance from the
Mees line to the proximal nail fold, as one can do with Beau's lines.
Leukonychia totalis
Leukonychia totalis is a rare nail disorder which may be hereditary or acquired.
Hereditary or congenital leukonychia, 102 is present since birth, with positive family
history and has autosomal dominant inheritance. Acquired leukonychia totalis appears
in early childhood .102 The white nail has been associated with various diseases or
with occupation. Frequently the cause may be obscure. Albright quoted Giovannini
that leukonychia totalis develops after typhoid fever. Baran and Drawber also reported
leukonychia after infectious diseases such as measles and herpes zoster.103
The other causes may be leprosy, exposure to extreme cold, hepatic cirrhosis,
ulcerative colitis, onychophagia, anemia, hypoproteinemia or occupational trauma.
Longitudinal melanonychia
Longitudinal melanonychia, brown-pigmented longitudinal streaks of the nail, may be
a normal variant in darker-skin individuals or they may actually be nevi. Less
commonly, they may represent Addison's disease, acanthosis nigricans, Peutz-Jeghers
syndrome, trauma, subungual hemorrhage and fungal infection, or even an underlying
melanoma, especially when they occur on the thumb (most common site for
melanoma of the nail unit). Black discoloration of the proximal nail fold at the base of
the pigmented streak (Hutchinson's sign) is an ominous sign for melanoma.
Longitudinal melanonychia in one nail without an obvious explanation warrants a
biopsy of the nail matrix.
Muehrcke's Lines
Muehrcke's lines are double white transverse lines that represent an abnormality of
the nail vascular bed. Squeezing the distal digit will cause the lines to disappear

temporarily. They are not palpable and do not indent the nail, and it has been noted
that they are usually found on the second, third, and fourth fingernails.104 They
sometimes occur when chronic hypoalbuminemia persists and tend to disappear when
the serum albumin is above 2.2 g/100 ml.
A number of disease states causing hypoalbuminemia may be associated with
Muehrcke's lines, such as the nephrotic syndrome and glomerulonephritis. Liver
disease and malnutrition are .among those that have been mentioned.
Half-and-Half (Lindsay's Nails)
Lindsay's nails (half-and-half nails) are associated with chronic renal insufficiency
(see p. 164). They are form of apparent leukonychia exhibiting either a whitish, or
normal proximal half and a distinctly abnormal brownish distal portion. This distal
portion begins proximally where the normal or whitish nail ends and terminates
distally where the free end of the nail loses its attachment to the hyponychium. 105, 106
Lindsay's description, as well as crescents, are seen frequently in renal failure but nor
infrequently otherwise.107 Psoriasis is the most common cause of a pseudo half-andhalf nail appearance.
Terry's Nails
In 1954, Terry described apparent leukonychia over the entire nail bed with narrow
distal pink band in 82 of 100 cirrhotic patients.108 In a large prospective study,
Holzberg and Walker revised the description to include a pink brown band 0.5-3:0
mill wide, which histologically demonstrated telangectasias in the dermis,

109

Their

study showed association with cirrhosis, congestive heart failure, diabetes mellitus,
and age. When seen in younger individuals, Terry's nails should prompt consideration
of an investigation for systemic disease.
Thyrotoxicosis, pulmonary eosinophilia, malnutrition, or 'keratoses' were found in
other patients who had Terry's nails but who did nor exhibit cirrhosis.110 We have
noticed numerous patients who had a similar nail appearance (but who never had liver
disease). And we concluded that this disorder is a reaction pattern and is not
pathognomonic for cirrhosis (also see the following discussion of eiyrhematous
crescents).

Melanonychia:
Nails that show bands of black or brown pigmentation. This colorization can be
localized or diffuse. In ethnic groups with more pigmented skin such as black, Asians
and Hispanics this is a common finding. It is also seen in acanthosis nigricans,
secondary to medication (minocycline, azidothymidline, antimalarials). In higher skin
types these pigmented bands are associated with nevi or melanoma.

MATERIAL AND METHODS

This was a prospective study on nail disorders done in tertiary care center hospital.
Patients to be included were those coming to the Outpatient Department of
Dermatology.
The inclusion criterion was all patients seeking advice for nail complaints and all
patients who have nail changes during examination. Data of each patients included
demographic data regarding age, sex, address & occupation.
For each of these patients included in the study a detailed record was maintained in a
case record form. A careful history of nail disease was noted with special reference to
the onset, duration & progression of nail disease. Complaints like loss of nails, pain in
nail folds, structural/physical changes in the nail, changes in color of nails was noted.
A careful history was taken for any trauma, drug intake, contact with chemical,
systemic illness, congenital or acquired disease, history of similar illness in past and
history of cutaneous/ mucosal/ hair complaints.
Past history of similar nail disease or systemic disease like diabetes, hypertension,
tuberculosis, atopy, immunocompromised status was taken.
Treatment history for other diseases or nail complaints was asked.
Family history of similar nail disorder was asked.
Examination included a thorough cutaneous & orogenital examination.
Nail examination was carried out and the nail signs were categorized into shape,
surface and color as described in Rook's textbook of dermatology
The following points were noted
1) No of nails affected
2) Involvement of finger nails or toe nails
3) Abnormalities in nail shape
4) Abnormalities in nail attachments
5) Change in nail surface

6) Change in nail color

We categorized the nail disorders as per the classification given in Moschella textbook
of dermatology in the chapter on "Disorders of the nails".
Routine investigations like blood sugar, liver function, renal function tests & x-ray
chest done. Specific investigation if required like potassium hydroxide mount,
chlorazol black e mount, culture sensitivity, if required nail matrix biopsy was done.
Finally based on the history, clinical examination and investigations a probable
diagnosis of nail disorder was made and appropriate treatment was given.
After completion of study, data analysis was done as per the classification mentioned
above.

OBSERVATION
&
RESULTS

Sex wise distribution (table 1)

Males
Females
Total

139
111
250

55.6
44.4
100

Occupation wise distribution (table 2)

Occupation
Manual laborer
Housewife
Office worker
Student
Not working
Business
Hotel work
Total

No of patients
81
39
35
30
25
20
20
250

Percentage
32.4
15.6
14.0
12.0
10.0
08.0
08.0
100.0

Complaints (table 3)
Complaints
Discoloration
Pain & swelling
Physical change
Total

No of patients
39
28
26
93

Percentage
15.6
11.2
10.4
37.2

Cutaneous complaints associated with nail changes (table 4)

Cutaneous complaints
Itchy lesions over palms & soles
Scaly lesions over body
Voilaceous lesions
Hair loss
Total

No of patients
64
27
10
09
110

Percentage
25.6
10.8
04.0
03.6
44.0

Number of nails affected (table 5)

Cutaneous complaints
Both finger & toe nail
Finger nails
Toe nails
20 nails
Total

No of patients
106
67
52
25
250

Percentage
37.2
26.8
20.8
10.8
100

Nails disease observed (table 6)

Complaints
Genetic / developmental disorders of the nail
Nail changes in dermatologic diseases
Nail changes due to trauma
Infections of nail
Abnormalities of shape & colour
Total

No of patients
13
64
6
130
37
250

Percentage
5.2
25.6
2.4
52
14.8
100

Nail diseases observed

Nail diseases

No of

Percentage

patients
Anonychia
Darriers disease
Epidermolysis bullosa
Pachyonychia congenita
Tuberous sclerosis

02
05
02
01
03

00.8
02.0
00.8
00.4
01.2

Psoriasis
Eczema
Lichen planus
Alopecia areata
Vesiculobullous disease
Collagen vascular disease
Reiters disease
Drug reactions

25
11
10
09
02
02
03
02

10.0
04.4
04.0
03.6
00.8
00.8
01.2
00.8

Subungal hematoma
Ingrowing toe nail
Onychogryphosis

03
02
01

01.2
00.8
00.4

Warts
Bacterial Infection
Fungal infection

02
17
111

00.8
06.8
44.4

Koilonychia
Platynychia
Clubbing
Melanonychia
Total

13
05
04
15
250

05.2
02.0
01.6
06.0
100

Congenital /developmental nail disorders (table 7)

Nail changes
Darriers disease
Tuberous sclerosis
Epidermolysis bullosa
Pachyonychia congenital
Anonychia
Total

No of patients
5
3
2
1
2
12

Percentage
2.0
1.2
0.8
0.4
0.4
4.8

Dermatoiogical disorders (table 8)

Dermatoiogical disorders
Psoriasis
Eczema
Lichen planus
Alopecia areata
Reiters disease
Collagen vascular disease
Drug reactions
Vesiculobullous disease
Total

No of patients
25
11
10
09
03
02
02
02
64

Percentage
10.0
04.4
04.0
03.6
01.2
00.8
00.8
00.8
25.6

Nail changes in psoriasis(table 9)

Changes
Pitting
Long ridiging
3eaus lines
Subungual hyperkeratosis
^ail discoloration
Onychochauxis
Oil drop sign
Onycholysis

No of patients
15
10
09
07
06
06
04
03

Percentage
60
40
36
28
24
24
16
12

Nail changes in Lichen planus(table 10)

Nail changes
Long ridging
Nail discoloration
Pterygium
Pitting
Onycholysis
Anonychia

No of patients
4
2
2
2
1
1

Percentage
1.6
0.8
0.8
0.8
0.4
0.4

Nail changes in trauma (table 11)

Nail changes

No of patients

Percentage

Subungal hematoma

1.2

Pterygium

0.8

Ingrowing toe nail

0.8

Onychogryphosis

0.4

Total

3.2

Nail changes in systemic diseases(table 12)

Nail changes

No of patients Percentage

Koilonychias

13

5.2

Leukonychia

09

3.6

Clubbing

04

1.6

Total

26

10.4

Infectious nail diseases (table 13)

Infection
Onychomycosis
Paronychia
Subungual wart
Total

No of patients
111
17
02
130

Percentage
44.4
6.8
0.8
52.0

Pattern of onychomycosis (table 14)

Pattern
Distal and lateral subungual onychomycosis
White superficial onychomycosis
Candidial onychomycosis
Proximal subungual onychomycosis
Total dystrophic onychomycosis

No of
patients
72
11
11
10
07

Percentage
64.86
09.9
09.9
09.0
06.34