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Nail disorder - Dr Aisha Almoosa
- 1. Nail disorder By: AishaAl-Moosa
- 2. Nail Anatomy: Onycho= NAIL
- 3.
- 4. Nail plate The nailplate is a hard, semitransparent, slightly convex sheet comprised of tightly packed corneocytes termed onychocytes. • It contains abundant “hard” hair-type keratins, which are embedded in a matrix of sulfur-rich high-cysteine and high-glycine/tyrosine proteins. • Pink color of nail plate due to longitudinally situated subungual capillaries
- 5. • The nailplate is surrounded on three edges by nail folds (one proximal and two lateral).
- 6. • Nail bedrepresents its underlying support structure and extends from the distal margin of the lunula to the onychodermal band.
- 7. • The proximalnail fold, a double layer of skin overlying the proximal part of the nail. • Protects this area from trauma, solvents and infectious agents that might otherwise alter nail shape and structure.
- 8. The cuticle (eponychium) Isa thin strip of cornified epithelium that adheres to the nail at the edge of the proximal nail fold and acts as a seal against ingress. • Damage to the cuticle results in a predisposition to inflammation of the nail fold; conversely, inflammation of the nail folds disrupts normal maturation of the epithelium and cuticle formation
- 9. The dermis ofthe nail apparatus • Is a fibrocollagenous network that is “sandwiched” between the hard tissues of the nail plate and the underlying bone, lacking associated subcutaneous soft tissues or pilosebaceous units.
- 10. • Bacterial infectionsin this region have a higher risk of spread to the adjacent bone (i.e. osteomyelitis of the distal phalanx) than in most other sites of the body.
- 11. Lunula • The half-moon-shapedlunula, which is most prominent on the thumb, demarcates the junction between the matrix and the nail bed.
- 12. Nail Matrix • Isthe germinative epithelium from which the nail plate is derived. • Wedge-shaped area of specialized epithelium, divided into proximal and distal portion • Lunula demarcates distal portion of nail matrix • Melanocytes found in high concentration in nail matrix (mainly seen in the distal matrix)
- 13. • Proximal matrix→ dorsal nail plate • Distal matrix (lunula) → ventral nail plate
- 14. Embryologic development ofthe nail apparatus
- 15. Growth • Fingernails usuallygrow faster than toenails • Fingernails: 2–3 mm/month • Toenails: 1 mm/month • Complete replacement of a nail requires 6 (fingernails) to 18 months (toenails) • In children the growth is rapid 6 – 8 weeks • Nail growth is quicker: · During pregnancy · In the summer than in the winter · On the hands than the feet
- 16. CORRELATION OF NAILFINDINGS WITH ANATOMIC SITE OF NAIL DAMAGE
- 18.
- 21. Beau’s lines Single horizontalridge OR Transverse depressions More evident in the central portion of the nail plate Description Mechanical trauma (e.g. manicures, onychotillomania) Dermatologic disease of the proximal nail fold (e.g. eczema, chronic paronychia). The presence of Beau’s lines at the same level in all nails suggests a systemic cause (e.g. severe or febrile illness, erythroderma, drugs). Causes
- 23. Onychomadesis (nail shedding) Detachmentof the nail plate from the proximal nail fold Description •Traumatic •Medications (i.e. chemo), •Drug reaction (i.e. TEN), •Systemic illness Causes
- 25. Pitting Punctate depressions ofthe nail plate surface Elkonyxis: large 2-mm pits Description •Psoriasis •Alopecia areata •Eczema Causes
- 27. Onychorrhexis Thinning Longitudinal ridging andfissuring Description •Lichen planus •Impaired vascular supply •Trauma •Tumors that compress the nail matrix. •Repeated wet/dry cycles, • Normal with aging Causes
- 29. Trachyonychia (twenty-nail dystrophy, sandpaperednails) Nail roughness Often associated with thinning Description •Alopecia areata (common) •Lichen planus (rare) •Psoriasis (rare) •Eczema (very rare) Causes
- 31. True leukonychia White opaquediscoloration Distal nail matrix damage Description Most often traumaticCauses
- 32.
- 34. Punctate leukonychia • Thenail plate shows small opaque white spots • Move distally with nail growth and sometimes disappear before reaching the distal nail. • It is caused by trauma and is most commonly observed in the fingernails of children.
- 36. Striate leukonychia The nailplate shows one or more transverse white opaque parallel lines. • Observed in the fingernails of women, due to matrix trauma secondary to manicures.
- 38. Diffuse leukonychia • Thenail plate is completely or almost completely opaque and white. • Chemotherapy • White superficial onychomycosis • Congenital disease
- 39. Needs to bedistinguished • Apparent leukonychia (nail bed discoloration) ( White discoloration (fades with pressure) nail plate looks white but normal color) • Pseudoleukonychia (nail plate invasion by fungi), which is typical of superficial white onychomycosis In this case the nail plate surface is friable due to the presence of keratin debris and fungal elements
- 41. Koilonychia (spoon nails) Thinnedconcave nails The nail plate is thinned, flat and spoonshaped due to upward eversion of its lateral edges. Description •Physiologic in the toenails of children •Adults -- occupational •Severe iron deficiency. Causes
- 42. Nail Signs dueto Nail Bed Disorders
- 44. Onycholysis Distal nail platedetachment Detached nail looks yellow–whiteDescription •Environmental trauma •Psoriasis •Onychomycosis •Photoonycholysis •Hyperthyroidism •Medications such as tetracycline. •Tumors •Subungual exostoses •SCC Causes
- 46. Onychauxis The nail plateappears thickened due to the presence of subungual scales.Description •Psoriasis, •Onychomycosis •Eczema Causes
- 48. Apparent leukonychia The nailsare white because of abnormalities in the color of the nail bed and this is usually due to nail bed edema. Apparent leukonychia does not move distally with nail growth and the white discoloration fades with pressure Description Drugs (i.e. chemo agents) or systemic diseaseCauses
- 50. Splinter hemorrhages Thin, longitudinalred-brown lines along nail plateDescription •Trauma •PSO •fungal (distal) •Endocarditis •Vasculitis •Trichinosis (proximal) Causes
- 51.
- 53. Longitudinal melanonychia Longitudinal brownto black band Commonly seen in darkly pigmented individuals Description •Nevus •Lentigo •Drugs •Trauma •Melanoma Causes
- 55. Hutchinson’s sign •Brown–black periungualpigmentation • Needs to be distinguished from pseudo- Hutchinson’s sign (dark bands producing “illusory” pigmentation of the proximal nail fold due to cuticle transparency) Description •Possible sign of nail melanomaCauses
- 57. Green nail syndrome nailhas a greenishblack or greenishblue color due to the deposition of pyocyanin, a blue–green pigment produced by Pseudomonas aeruginosa, Predisposing factors • Prolonged exposure to water, • Detergents and soaps, • Nail trauma in barbers, dishwashers, bakers and medical personnel. Description •Pseudomonas aeruginosaCauses
- 59. Half and halfnails (Lindsay’s nails) Proximal ½ with white zone, distal ½ with red-brown zoneDescription •Chronic renal diseaseCauses
- 61. Terry’s nails Proximal 2/3white nail color, distal 1/3 brown-pink bandDescription •Cirrhosis, •Hypoalbuminemia •Diabetes •cardiac disease Causes
- 63. Muehrcke’s bands Transverse whitebands parallel to lunula Description •Hypoalbuminemia •Chemotherapy Causes
- 64. Color changes due todrugs: • Chloroquine may produce blue-black pigmentation of the nail • Arsenic may produce longitudinal bands of pigment or transverse white stripes (Mees' stripes) across the nail
- 65.
- 67. Racquet Thumbs (Brachyonychia) •Distal phalanx short/wide • Form of brachyonychia • Rubinstein-Taybi syndrome,
- 69. Absent lunula • Novisible lunula • Yellow nail syndrome, • Renal failure, • Trauma
- 70. Yellow nail syndrome •The nails are yellow due to thickening, sometimes with a tinge of green • The lunula is obscured and there is increased transverse and longitudinal curvature and loss of cuticle • It is usually accompanied by lymphoedema and pleural effusions
- 72. Anonychia • Absence ofnail • Nail patella syndrome • COIF (Congenital Onychodysplasia of the Index Finger) scarring
- 74. Blue lunula • Bluediscoloration of lunula • Wilson’s • Drugs • PUVA • Argyria
- 76. Clubbing • ↑ Nailcurvature w/ bulbous growth of tip of digit
- 77. Causes of clubbing 1-Primary(idiopathic) clubbing e.g. familial clubbing 2-Secondary clubbing include the following: • Pulmonary disease e.g. Lung cancer, cystic fibrosis • Cardiac disease e.g. Cyanotic congenital heart disease • GIT disease e.g. inflammatory bowel disease • Skin disease e.g. Pachydermoperiostosis • Malignancies e.g. Thyroid cancer, Hodgkin disease, leukemia • Miscellaneous conditions e.g. Acromegaly, pregnancy, and hypoxemia possibly related to long-term smoking of cannabis
- 79. Dorsal pterygium • Wing-likegrowth fusing PNF with nail bed/matrix • Lichen planus , • epidermal bullosa, • TEN, • GVHD, • Cicatricial pemphigoid
- 80. Ventral pterygium (Pterygium inversumunguis) • Fusion of hyponychium to distal nail plate • Familial • Trauma • systemic sclerosis • Lupus erythematosus
- 82. Habit tic deformity •Parallel horizontal grooves Caused by repetitive trauma to cuticle
- 84. Onycho-gryphosis: (gryphosis: thick) •Thick, yellow and twisted great toenail in the elderly • Due to repetitive trauma by footwear
- 86. Ingrowing toenail (Onychocryptosis): •The edge of the nail plate penetrates the lateral nail fold • Due to compression of the toe from the side due to ill-fitting footwear
- 88. Pincer nails • Overcurvaturelateral portion Pressure (ill-fi tting shoes), • Hereditary
- 90. Triangular lunula • Triangularshape of lunula • Nail-patella syndrome
- 92. V-shaped nicking • V-shapednick at free margin • Darier disease
- 93.
- 94. – Keratosis follicularis(Darier’s disease) is associated with each of the following nail changes EXCEPT: A. “V-shaped” notch at the nail plate’s distal free edge. B. Splinter hemorrohages. C. Proximal nail fold keratotic papules. D. “V-shaped” lunula E. Longitudinal dyschromic lunular bands.
- 95. • Nail changesin Pachyonychia congenita are most consistent with Which of the following descriptions? A. Congenital malalignment B. Leukonychia C. Koilonychias D. Subungual hyperkeratosis E. Onychomadesis
- 96. • Hutchinson nailsign is periungual extension of pigment to the proximal and lateral folds of the nail and is noted in: A. LP B. Traumatic purpura C. Onychomycosis D. Subungual melanoma E. Periungual fibroma
- 97. • Which Oneof the following definition about nail changes is not true : A. Roughened surface of the nail plate is trachyonychia B. Longitudinal striations of the nail plate is onychmadesis C. Ingrown nail is onychocryptosis D. A traumatic, familial non- inflammatory nail loss is onychoptosis E. Superficial splitting of the nail plate or near the free edge is onychoschizia
- 98. • The dorsalnail plate is produced by : a. Proximal matrix b. Nail bed c. Nail fol d. Hyponychium e. Distal matrix
- 99. • Pitting ofthe nail plate in psoriasis is associated with involvement of which portion of the nail apparatus? • A. Proximal nail matrix. • B. Distal nail matrix. • C. Cuticle. • D. Nail bed. • E. Nail plate.
- 101. • One ofthe following is not true about yellow nail syndrome: A. yellow thickened nails B. Increased longitudinal and transverse curvature C. Triangular lunula D. Decreased growth rate of nails E. Lymphedema mostly in legs
- 102. • Transverse grooveson nail following systemic disease are called: • A. Mee’s line. B. Coenen’s line. C. Trachyonychia. D. Beau’s line E. Grove sign.
- 103. • The nailfindings shown here are most characteristic of what condition? • A. Lichen planus. • B. Lichen striatus. • C. Darier’s disease. • D. Dyskeratosis congenita. • E. Pachyonychia congenita.
- 104.
- 105. Nail infections Paronychia: isa soft tissue infection around a fingernail • is the most common hand infection Acute paronychia • nail biting breaks down the physical barrier between the nail bed and the nail allowing the infiltration of infectious organisms • S. aureus is the most common infecting organism. • pain, tenderness, and swelling in the lateral folds of the nail • erythematous and swollen, pus collects under the skin of the lateral fold • Oral antibiotics Chronic paronychia • After 6 weeks or longer • The nail folds are swollen, erythematous, and tender with pronounced transverse ridges • Cause is a mixture of C. albicans and bacteria • Can be a complication of eczema • In housekeepers, dishwashers, and swimmers
- 106. Pseudomonas infection • Itis always a complication of onycholysis or chronic paronychia • The nail plate has a characteristic bluish-black or green color due to accumulation of the pigment pyocyanin below the nail which may remain after the organism has been removed • Treatment is as for paronychia ONYCHOMYCOSIS (TINEA UNGUIUM) • An infectious fungal disease mainly seen as white spots that can be scraped off the surface, or long yellowish streaks within the nail substance. • attacks the free edge and moves its way to the matrix. • The infected portion is thick and discoloured.
- 107. 4-Tumors Warts Fibrokeratoma: periungual hyperkeratotictip Subungual exostosis: bony outgrowth of the distal part of the toe Glomus tumour: •is painful, (pain may be spontaneous or evoked by mild trauma or temperature change) •Nail-plate changes depend on the location of the tumour: - Matrix tumours cause splitting and distortion of the nail plate. - Nail bed lesions appear as bluish or red foci of 1-5mm diameter beneath the nail
- 108. Squamous cell carcinoma:hyperkeratotic, warty changes, erosions and fissuring, macerated cuticle, periungual swelling & erythema Melanocytic nevi: longitudinal melanonychia Malignant melanoma: features suggest the possibility of malignant melanoma: •75% will have Longitudinal melanonychia •Brown-black periungual pigmentation in a single digit in adult life •The pigmentation becomes darker and broader and has blurred edges