The nail organ is an integral component of the digital tip. It is a highly versatile tool that protects the fingertip, contributes to tactile sensation by acting as a counterforce to the fingertip pad, and aids in peripheral thermoregulation via glomus bodies in the nail bed and matrix. Because of its form and functionality, abnormalities of the nail unit result in functional and cosmetic issues ...

1. 2017
FACEDOUX
Dr.Mohammad Baghaei
FINGERNAIL AND TOENAIL
ABNORMALITIES
The nail organ is an integral component of the digital tip. It is a highly versatile tool that protects the
fingertip, contributes to tactile sensation by acting as a counterforce to the fingertip pad, and aids in
peripheral thermoregulation via glomus bodies in the nail bed and matrix. Because of its form and
functionality, abnormalities of the nail unit result in functional and cosmetic issues

2. A brief review of Nail Disease by, Dr. Mohammad Baghaei, Cosmetic Scientist
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Fingernail and Toenail Abnormalities
A brief review of Nail Disease by, Dr. Mohammad Baghaei, Cosmetic Scientist
The nail organ is an integral component of the digital tip. It is a highly
versatile tool that protects the fingertip, contributes to tactile
sensation by acting as a counterforce to the fingertip pad, and aids in
peripheral thermoregulation via glomus bodies in the nail bed and
matrix. Because of its form and functionality, abnormalities of the
nail unit result in functional and cosmetic issues. The structures that
define and produce the nail (nail plate) include the matrix (sterile
and germinal), the proximal nail fold, the eponychium, the
paronychium, and the hyponychium .
Collectively, the nail bed (sterile matrix), nail fold, eponychium,
paronychium, and hyponychium are referred to as the perionychium.

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Nail Growth
Development of the nail matrix begins in the ninth embryonic week
from the nail anlagen. By week 16, the fetal nail is
identifiable. Nearly 90% of the nail plate is produced by the proximal
half of the matrix, more specifically, the germinal matrix. As a result,
more of the nail plate substance is produced proximally, leading to a
natural convex curvature of the nail from proximal to distal. Ulnar
and radial projections of the matrix extend proximally to form points
or horns of the matrix. These lateral horns are attached to the dorsal
expansion of the lateral ligament of the distal interphalangeal joint
(DIP).
Nail growth is separated into 3 areas: (1) germinal matrix, (2) sterile
matrix, and (3) dorsal roof of the nail fold.
The germinal matrix has the following characteristics:
 It is found on the ventral floor of the nail fold; The nail is
produced by gradient parakeratosis

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 Cells near the periosteum of the phalanx duplicate and enlarge
(macrocytosis)
 Newly formed cells migrate distally and dorsally in a column
toward the nail
 Cells meet resistance at established nail, causing them to flatten
and elongate as they are incorporated into the nail
 It initially retains nuclei (lunula); more distal cells become
nonviable and lose nuclei
The sterile matrix has the following characteristics:
 The area is distal to the lunula
 It has a variable amount of nail growth.
 It contributes squamous cells, aiding in nail strength and
thickness
 It has a role in nail plate adherence by linear ridges in the sterile
matrix epithelium
The dorsal roof of the nail fold has the following characteristics:
 The nail is produced in a similar manner as the germinal matrix
 The cells lose nuclei more rapidly
 It imparts shine to the nail plate
Nail growth is estimated at 3-4 mm per month. Complete nail plate
growth takes approximately 6 months. Certain factors increase the
rate of the growth. These include longer digits, summer months,
young persons (< 30 y), and nail biters.

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Fingernail and Toenail Abnormalities

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Hamman-Rich syndrome (acute interstitial pneumonitis)
Nail clubbing has been associated with various underlying pulmonary
and cardiovascular disorders, as well as with neoplastic, infectious,
hepatobiliary, mediastinal, endocrine, and gastrointestinal diseases.
Nail clubbing occurs when the angle made by the proximal nail fold
and the nail plate, termed the Lovibond angle, is greater than 180°
(shown).Hamman-Rich syndrome, or acute interstitial pneumonitis, is
a form of idiopathic interstitial pneumonia that is characterized by
inflammation of the lung interstitium. With advanced interstitial lung
diseases, digital clubbing and signs of right heart failure may appear.

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Fungal infections of the fingernails and toenails (onychomycosis)
Fungal infections of the fingernails and toenails (onychomycosis) .
Onychomycosis is a common fungal infection of the nail that is
most frequently caused by a dermatophyte. Onychomycosis is
most prevalent in the toenails of adults and is more commonly
found in patients with certain comorbid diseases such as diabetes,
tinea pedis, and psoriasis. Management of onychomycosis includes
a multispecialty team of healthcare providers. Early treatment of
this infection, and new topical therapies are providing expanded
options so clinicians can individualize treatment for this difficult to
manage condition.

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Lunula
The lunula (shown) is most noticeable on the thumb, although the
eponychium may partially or completely cover the lunula. Absence
of the lunula (anolunula) of the thumb should prompt investigation
for anemia or malnutrition. However, this may also be a normal
finding. Anolunula of other digits is nonspecific.
Absence of the lunula may indicate the need to perform a complete
blood count.
The lunula is the distal extent of the germinal matrix of the nail
bed. Abnormalities of the lunula are common and may lead
clinicians down varied diagnostic paths. A pyramidal lunula may be
a sign of excessive manicure or trauma. A pale blue lunula may
indicate diabetes mellitus, whereas a red discoloration of the
lunula may signify cardiovascular disease, collagen vascular
disease, hematologic malignancy, or another serious diagnosis. The
nail shown is lacking the lunula.

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Yellow nail syndrome
Yellow nail syndrome is an extremely rare disorder characterized by
malformations affecting the fingernails and toenails, abnormalities affecting
the lungs and the airways (respiratory tract), and swelling or puffiness in
different parts of the body because of the accumulation of protein-rich fluid
(lymph) in the soft layers of tissue under the skin (lymphedema). Yellow nail
syndrome usually affects older adults. The exact cause of yellow nail
syndrome is not known. Occasionally, yellow nail syndrome has been
reported to run in families suggesting that genetic factors may play a role in
the development of the disorder in these cases. The treatment of yellow nail
syndrome is geared toward the symptoms present in each individual.
Treatment may include antibiotic therapy for repeated respiratory infections.
The yellowed, malformed nails may improve without therapy. In some cases,
the changes may be permanent. Vitamin E has been used to treat nail
changes. Corticosteroids have also been used to treat individuals with yellow
nail syndrome. Surgical management of respiratory problems such as pleural
effusions has been used in some cases.
Genetic counseling may be of benefit for affected individuals and their
families. Other treatment is symptomatic and supportive.

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Koilonychia
Koilonychia is an abnormality of the nails that is also called spoon-
shaped (concave) nails
It is primarily recognized as a manifestation of chronic iron
deficiency, which may result from a variety of causes, such as
malnutrition; gastrointestinal blood loss; worms; gastrointestinal
malignancy; and celiac disease diabetes mellitus, protein deficiency
(especially in sulfur-containing amino acids), and Raynaud disease,
as in the present case. Other causes of koilonychia are high
altitude, trauma, and exposure to petroleum products, and it can
even be hereditary. Therefore, spoon-shaped nails should prompt
an evaluation for possible iron deficiency and the underlying cause.

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half nails-and-Lindsay half
half nails refers to a condition in which the proximal-and-The term Lindsay half
80%) of the nail bed is white and the distal portion is dark (red,-portion (40
edema and anemia. These nailspink, or brown). The white portion is related to
are indicative of renal disease. Terry nails refer to nail beds in which the
proximal 80% of the nail bed is white and the distal portion is a normal pink
nail bed.); the condition is caused by a decreased vascular supply to theshown(
Terry nails are indicative of hepatic disease, although they can also suggest
.diabetes mellitus, congestive heart failure, hyperthyroidism, and aging
half nails, were described in 1967 as red, pink, or-and-Lindsay’s nails, or half
cupying 20 to 60% of the nail bed in patients with chronicbrown bands oc
kidney disease. There is no correlation between the degree of azotemia and
the percentage of nail bed that is occupied. The proximal white band is
n band from increasedthought to result from chronic anemia and the brow
-melanin deposition distally, possibly from an increased concentration of β
stimulating hormone. There is no specific therapy beyond the–melanocyte
.treatment of the underlying chronic kidney disease

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Proximal (white) subungual onychomycosis
Proximal subungual onychomycosis (PSO) is a rare fungal nail
infection that is associated with immunodeficiency or local trauma.
The white patch initially appears under the nail fold, but it
progressively migrates distally with nail growth. If PSO is caused by a
mold, marked periungual inflammation is usually present. PSO
requires systemic antifungal treatment when the lunula is involved;
topical agents may be sufficient when only the distal nail is affected.
In contrast, onycholysis (shown) is the distal separation of the nail
plate from the underlying nail bed, usually no inflammation is
involved. It is associated with conditions such as thyrotoxicosis,
psoriasis, eczema, trauma, contact dermatitis, tetracycline, toxic
exposures (solvents), blistering from autoimmune disease, and
porphyria cutanea tarda (onycholysis and skin blistering from sun
exposure). Therapy is dependent on the etiology and includes
removing the predisposing cause, keeping the nails short, and
avoiding exposure to contact irritants and moisture.

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Longitudinal brown lines
Longitudinal brown lines (arrows) form as a result of increased
melanin production by nail matrix melanocytes.These lines are
associated with Addison disease, a melanocytic nevus at the nail
base, breast cancer, melanoma (check for periungual
pigmentation), and trauma. Longitudinal Linear Lesions
Longitudinal pigmented bands are normal findings in the nails of
dark-skinned persons, occurring in more than 77 percent of blacks
older than 20 years. These findings present a diagnostic problem
because they must be differentiated from subungual melanomas,
which also occur in older age groups and constitute 50 percent of
melanomas in dark-skinned populations.

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Beau lines
Beau lines (arrow) are transverse depressions in the nail plate
resulting from temporary cessation of nail growth. Causes include
intermittent doses of immunosuppressive therapy or
chemotherapy, nail injury, cold temperatures, and illness. Severe
zinc deficiency has also been proposed as a cause of Beau lines. By
noting the location of a Beau line on the nail, a clinician can
determine the approximate date of the illness associated with it.
Moreover, the depth of the line provides a clue to the severity of
the illness.

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Onychorrhexis
Onychorrhexis, or the presence of longitudinal striations or ridges
on the nail plate, can simply be a sign of advanced age, but it may
also be associated with conditions such as rheumatoid arthritis,
peripheral vascular disease, lichen planus, and Darier disease
(broad white and red striations in the nails). A central vertical ridge
or groove may be due to myxoid cysts (shown) that appear near
the nail fold; myxoid cysts are associated with osteoarthritis.

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Splinter hemorrhages
Splinter hemorrhages are caused by small areas of bleeding of the
distal capillary loops in the nail bed and are most commonly
associated with subacute bacterial endocarditis (classic finding) and
local trauma.
These red or brown linear hemorrhages (shown) may also be
associated with vasculitis, micro emboli, trichinosis, onychomycosis
, psoriasis, SLE, pityriasis rubra pilaris, or renal failure.

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Pitting
Small punctate depressions of the nails, or "pitting" (shown), is
caused by proximal nail matrix inflammation. Nail pitting is caused
by defective development of the layers of the superficial nail plate.
It is common in patients with psoriasis and can affect up to 50% of
people suffering from this condition. Nail pitting can also be
associated with other conditions, including connective tissue
disorders, alopecia areata, and sarcoidosis. Any condition that can
cause a superficial and localized inflammation of the skin
(dermatitis) can also affect the nails and result in nail pitting. Nail
pitting can be associated with other abnormalities of the nails,
including nail separation, flaking or crumbling, or other damage to
or changes in the nail. Nail pitting that is associated with disease
processes generally shows involvement of multiple or all nails,
while trauma to an individual nail bed can cause localized pitting or
disruptions in a single nail.

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Tuberous sclerosis
Tuberous sclerosis complex is a genetic disorder that causes benign
tumors to grow in many different organs. Ungual or periungual
fibromas may appear in adolescents or adults with tuberous
sclerosis. Fibromas may cause distortion of the nail or nail bed.
They can occur as an isolated sign of tuberous sclerosis. Generally,
when these fibromas involve the toes, they may bleed and cause
discomfort.
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