The presentation will show you different types of nail apparatus and its related conditions and also medication and treatment is shown here.

1. LOCAL DISORDERS OF
NAIL APPARATUS
PRESENTED BY- NIKHIL
GROUP-III

2. ANATOMY OF NAIL
 Nail plate
 Nail bed
 Nail matrix
 Proximal nail fold
 Cuticle
 Lanula

3. NAIL PLATE
 Fully keratinized structure .
 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.
 In transverse sections, the nail plate consists of three portions:
(1) dorsal nail plate
(2) intermediate nail plate
(3)ventral nail plate

4. PROXIMAL NAIL FOLD
 It has dorsal and a ventral portion.
 The dorsal portion is anatomically similar to the skin of the digit ,devoid of
pilosebaceous units.
 The ventral portion, proximally continues with the germinative matrix.
 Covers approximately one-fourth of the nail plate.

5. Cuticle
 The horny layer of the proximal nail
fold forms the cuticle firmly attached
to the superficial nail plate.
 Prevents the separation of the
plate from the nail fold..
Lanula
 The proximal part of the fingernails,
especially of the thumbs, shows a
whitish, opaque, half- moonshaped
area.
 Visible portion of the nail matrix.
 In this area the nail plate
attachment to the underlying
epithelium is loose.

6. Nail matrix
 The nail matrix is a specialized epithelial
structure that lies above the mid portion
of the distal phalanx.
 Proximal nail matrix – It forms
dorsal nail plate.
 Distal nail matrix(LANULA) – It forms
ventral nail plate.
 Following cells are present in nail
matrix.
1. NAIL MATRIX KERATINOCYTES
2. MELANOCYTES
3. LANGERHANS CELLS.
4. MERKEL CELLS
Nail bed
 Soft tissue upon which the nail rest.
 Extends from the distal margin of the
lanula to the isthmus.
 The nail bed epithelium is so adherent
to the nail plate that it remains
attached to the undersurface of the
nail.

7. NAIL SIGNS AS A FUNCTION OF
THE SITE OF PATHOLOGY
• BEAU’S LINES AND ONYCHOMADESIS
• Pitting
• Mees lines
• TRUE LEUKONYCHIA
• ONYCHORRHEXIS
• KOILONYCHIAor NAIL SPOONING
• TRACHYONYCHIA
• Onycholysis
• MELANONYCHIA

8. BEAU’S LINES AND
ONYCHOMADESIS
 BEAU’S LINES :Appear as transverse grooves,
often deeper in the central nail plate.
 ONYCHOMADESIS :The proximal nail plate is
detached from the proximal nail fold by a whole-
thickness sulcus.
 Result from a temporary arrest of proximal nail
matrix proliferation

10. PITTING
 Small punctate depressions of
the superficial nail plate which
progress distally.
 Indicates a defect in the
uppermost layer of the nail
plate, which arises from the
proximal nail matrix.
 Clusters of parakeratotic cells
seen in stratum corneum.

11. MEES LINES
 Transverse white band usually single.
 Result from focal parakeratosis of the
nail matrix.
 Causes:
1. Arsenic poisoning
2. Heart failure
3. Carbon monoxide poisoning
4. Leprosy
5. Chemotherapy

12. TRUE LEUKONYCHIA
 Defect in the distal nail matrix.
 Defective keratinasation leads to parakeratotic cells in the
• ventral nail plate.
 The superficial nail plate is structurally normal
 The nail presents with opaque white patches or striae.
 Types:
1. Leukonychia totalis
2. Leukonychia striata
3. Leukonychia partialis

13. ONYCHORRHEXIS
 Onychorrhexis results from diffuse
defective keratinization of the proximal nail
matrix.
 The nail plate is usually thinned and
presents multiple longitudinal ridges and
fissures.
 These are brittle nails that split
vertically.
 Causes:
1. Injury to matrix
2. Excessive use of solvents or cuticle polish
3. Aggressive filing
4. Vitamin deficiencies
5. Frequent exposures to strong soaps
6. Part of lichen planus

14. KOILONYCHIA OR NAIL
SPOONING
 Reverse curvature of longitudnal
and transverse axis of nail plate
leading to concave dorsal aspect of
nail.
 Pathogenesis : not known ; but
result of anoxia
 Physiologic in toe nails of children.

15. TRACHYONYCHIA
 Twenty-nail dystrophy or
sandpaper nail
 Diffuse homogenous nail
roughness
 Often associated
with thinning
 Causes:
1)Alopecia
areata
2) Lichen
planus
3)Psoriasis
4)Eczema

16. ONYCHOLYSIS
 Distal or distal lateral separation of the nail plate from the underlying
supporting structures (nail bed, hyponychium, lateral nail fold).
 The area of separation below the nail plate appears white or yellow
due to air beneath the nail.
 Discoloration may occur from the accumulation of bacteria, most
commonly pseudomonas or yeast.
 Common Causes:
1. Psoriasis
2. Lichen planus
3. Trauma
4. Fungal infection, Reiters syndrome, hyperhydrosis, pemphigus
vulgaris etc
5. Drug induced

17. Onycholysis with subungual
hyperkeratosis Plummer nails

18. INFECTIONS OF NAILS
• ACUTE PARONYCHIA
• CHRONIC PARONYCHIA
• GREEN NAILS
• ONYCHOMYCOSIS
• ONYCHOSCHIZIA

19. ACUTE PARONYCHIA
 Paronychia is a soft tissue infection around a fingernail that begins as
cellulitis but that may progress to a definite abscess.
 Acute paronychia - Painful and purulent condition; most
frequently caused by staphylococci.
 Typically affects a child’s fingernail.
 Predisposing factors include nail biting or sucking and occupational
traumas
 The proximal nail fold is painful,erythematous, and swollen.
 Pus may be discharged after pressure.
 If diagnosed early, acute paronychia without obvious abscess can
be treated with topical antibiotics alone.
 If an abscess has developed, incision and drainage must be
performed.

20. CHRONIC PARONYCHIA
 Occurs most commonly in food handlers and housecleaners.
 Associated with mechanical or chemical cuticle damage.
 Characterized by eczematous inflammation of the proximal nail fold and
matrix.
 Secondary colonization by bacteria and yeasts usually occurs.
 First, second, and third digits of the dominant hand are most often
affected.
 Management includes protective measures, topical and/or systemic
steroids, and topical antimicrobials.
 Systemic antifungals are not effective

21. GREEN NAILS
•The Gram-negative bacterium Pseudomonas
aeruginosa may colonize nail plate under
conditions, such as chronic paronychia or
onycholysis.
•The presence of Pseudomonas is revealed by
characteristic green–black nail pigmentation due to
pyocyanin staining.
•Topical application of diluted bleach or chlorhexidine
solution

22. ONYCHOMYCOSIS

23. DISTAL SUBUNGUAL
ONYCHOMYCOSIS
Proximal subungual
onychomycosis
White superficial
onychomycosis

24. ONYCHOSCHIZIA
•With nail fragility, the nails are brittle and show distal
lamellar splitting.
•The nail plate margin is irregular due to distal splitting.
•Idiopathic nail fragility usually affects middle-aged
women who are exposed to water and chemicals that
dehydrate the nail plate

25. SKIN DISEASES WITH SPECIFIC NAIL
CHANGES
• Nail Psoriasis
• LICHEN PLANUS
• NAPSI CALCULATION
• Alopecia areata

26. NAIL PSORIASIS
 Psoriasis is a chronic inflammatory skin disease characterized by T-cell-mediated
hyper proliferation of keratinocytes in the skin.
 Approximately, 10-78% of patients with psoriasis have concurrent nail psoriasis.
 Isolated nail involvement is seen in 5-10% of patients.
 Type 2 psoriasis predominantly damages the nails and the joints is not
associated with HLACw6.
 Pitting is the commonest manifestation of nail psoriasis.
 Pits affect the fingernails more commonly than the toenails.
 Coarse pits are common in psoriasis

27. Onycholysis along with pitting
and salmon patches in fingernails
Nail plate thickening with
discoloration and subungual
hyperkeratosis

28. LICHEN PLANUS
 Nail lichen planus is seen in approximately 10% of patients with skin
lichen planus.
 Nail involvement is not associated with oral, skin, or scalp lesions in
most cases.
 Nail matrix lichen planus produces nail thinning, with longitudinal
fissuring, dorsalpterygium, and trachyonychia.
 Nail bed lichen planus is frequent, but clinical signs are not specific
(onycholysis and mild subungual hyperkeratosis).
 Scarring of the nail matrix with dorsal pterygium is a possible
 Diagnosis should be confirmed by nail biopsy.

29. Pterygium typical of lichen planus

30. ALOPECIA AREATA
 Nail involvement is seen in approximately 20% of adults and 50% of
children with alopecia areata.
 It is most common in male patients with severe involvement.
 Geometric pitting is most typical. Pits are small,superficial, and
regularly distributed in a geometric pattern along longitudinal and
transverse lines.
 Trachyonychia is quite common in children affected by alopecia totalis
or universalis.
 Other nail abnormalities include punctate leukonychia, mottled lunulae,
and acute onycholysis

31. NAIL SIGNS OF SYSTEMIC DISEASES

32. Terry nails
• Proximal white nail with narrow distal
pink or brown band 0.5 to 2mm
• Causes:
Cirrhosis, CHF, Diabetes, Cancer, Ageing,
Hyperthyroidism, Malnutrition
Half and half nails
Proximal half of the nail plate is white but
distal half is red.
Present in 9 to 15% of chronic renal failure
patients.
• Also known as lindsay nails.

33. CLUBBING
 Thickening of the soft tissue
beneath the proximal nail plate
resulting in sponginess of the
plate.
 In clubbing the diamond
shape between the nails is
lost.

34. TRAUMATIC NAIL DISORDERS
• ONYCHOGRYPHOSIS
• INGROWING TOENAILS
• RETRONYCHIA
• Agnail or hang nail
• Pincer nails

35. ONYCHOGRYPHOSIS
 Onychogryphosis is common in
the elderly and neglected
individuals .
 The nail is thickened, distorted,
opaque, and yellow–brown.
 It tends to have an oyster shell
appearance.
 Avulsion of nail is recommended
in such cases.

36. INGROWING TOENAILS
 Ingrowing toenails most commonly
affect young adults with congenital
malalignment of the great toenails.
 Improper nail cutting may lead to
embedding of a nail edge.
 Causing inflammation and
granulation tissue formation.
 Hyperhidrosis is frequently
associated

37.  The aim of treatment for ingrowing toenails is to extract the nail edge
that is ingrowing and prevent further penetration of nail fragments into
the lateral folds.
 To accomplish this, the lateral nail plate can be lifted by using a
cotton pack or by inserting a gutter splint along the lateral nail
margin.
 The width of the nail plate can also be reduced by surgical or
chemical (phenolization) removal of the lateral nail matrix.

38. RETRONYCHIA
 Ingrowth of the proximal nail
plate into the proximal nail fold
associated with multiple
generations of nail plate
misaligned beneath the proximal
nail.
 Results in inflammation with pain
and granulation tissue formation.
 Nail plate avulsion leads to a
slow regrowth of a normal nail

39. HEREDITARY AND CONGENITAL NAIL
DISORDERS
• P
ACHYONYCHIACONGENIT
A
• ANONYCHIA

40. PACHYONYCHIA CONGENITA
 PC is an autosomal dominant genodermatosis characterized by
1. painful keratoderma
2. nail thickening
3. oral leukokeratosis
4. epidermal cysts.
 Occurs when there is a mutation in the genes encoding keratin, K6a, K16, K17, K6b
and, possibly, K6c (listed in decreasing frequency).
 Nail abnormalities are a constant feature and develop during infancy to early childhood.
 Nails are thickened, very difficult to trim, darkened, and with an increased transverse
curvature.
 Nail thickening is a consequence of nail bed hyperkeratosis and is more evident on the
distal half of the nails.

41. PACHYONYCHIA CONGENITA

42. ANONYCHIA
 Anonychia is the absence of nails, an anomaly, which may be the result of:
 a congenital ectodermal defect
 ichthyosis
 severe infection, severe allergic contact dermatitis
 self-inflicted trauma
 Raynaud phenomenon
 lichen planus
 epidermolysis bullosa
 or severe exfoliative diseases

43. MALIGNANT TUMORS OF NAILS
• SQUAMOUS CELL CARCINOMA
• MELANOMA

44. SQUAMOUS CELL CARCINOMA
• In situ squamous cell carcinoma (Bowen’s disease) usually manifests in fingernails,
with a lesion that clinically,closely resembles a wart.
• Associated melanonychia or paronychia may be a diagnostic clue.
• (HPV) 56 has been detected in tumoral cells of cases of Bowen’s diseases.
• Presents as a slowly growing subungual nodule that eventually ulcerates or a warty
periungual growth.
• The underlying bone is commonly involved.
• It is more common in the fingernails and after the fifth decade.
• Surgical excision with Mohs surgery is the best treatment for squamous cell carcinoma
without bone involvement.

45. SQUAMOUS CELL CARCINOMA

46. MELANOMA
• Nail melanoma is an uncommon form of acral melanoma that
arises within the nail matrix or bed.
• Involvement of nails is rare (0.7%–3.5% of melanomas).
• Nail melanoma most commonly affects the thumb or great toe of
middle-aged or elderly patient.
• Melanoma of the nail matrix presents as a band, usually dark in
color and with irregular border.
• Periungual brown–black pigmentation (Hutchinson nail sign)
indicates superficial spreading of the tumor and is a diagnostic
clue .
• An excisional biopsy is recommended in all cases showing
suspicious features.
• Up to 33% of subungual melanomas are amelanotic, and they are
often misdiagnosed as pyogenic granuloma or squamous cell
carcinoma