A bress power point on Nail examination

1. NAILS
Presented by
Dr. Ganga Suresh Tamilisetti
Post Graduate 1st
Year
General Medicine

2. ANATOMY OF NAIL UNIT
Consists of several key components:
• Nail Plate: The hard, visible part of the nail that protects the
underlying structures.
• Nail Bed: The skin beneath the nail plate that supports the
nail and contains blood vessels and nerves.
• Nail Matrix: The tissue under the base of the nail that
produces new nail cells, contributing to nail growth.
• Lunula: The visible part of the nail matrix, often seen as a
white crescent shape at the base of the nail.
• Cuticle: The layer of skin at the base of the nail that protects
the matrix from infection.
• Nail Folds: soft tissue structure that support the lateral and
proximal edes of nails platel
primarily made of keratin, a protein that provides strength.

3. • The nail grows from the
matrix and is supported by
the nail bed until it reaches
the free edge.
• At the proximal and lateral
margins, it is embedded in
the nail folds.
• Finger nails grow about 1 cm
in three months and toe nails
at about a third of this rate.
• Growth is slower in old age
and in the non-dominant
hand.
• Local and systemic diseases
can alter the appearance and
function of all four structures

4. Nail Examination Techniques
• Inspection: color, shape, surface, and
attachment
• Palpation: tenderness, consistency
• Capillary refill test
• Dermoscopy for detailed examination
• History taking and systemic correlation

5. NAIL PRESENTATIONS
• Longitudinal ridges: Single longitudinal ridges
may be caused by pressure from tumors,
either benign or malignant, in the proximal nail
fold.
• Multiple longitudinal ridges of varying size are
common in the elderly and in some conditions
such as lichen planus, rheumatoid arthritis,
psoriasis, alopecia areata and Darier's disease
(keratosis follicularis)

6. Hypertrophied nails
(Onychogryphosis) toe is
thickening of the nail, probably
due to repeated trauma are
more commonly associated with
the toes and may develop into
massivé "hornlike' structures
particularly on the big toe.
Trachyonychia is roughness of
the nails, so that they feel like
sandpaper.
• Usually symmetrical and can
occur in lichen ruber planus,
psoriasis, and alopecia areata.

7. Onycholysis. (Rat bitten nail) Detachment
of the nail from its nail bed with irregular
recession of junction is a characteristic
finding in hyperthyroidism,
hypothyroidism, Raynaud's disease,
porphyria, photo onycholysis (Tetracyclines
chlortetracycline, chloramphenicol).
psoriasis, trauma , fungal infections
Onychomadesis is complete shedding of
the nail and can occur in any severe illness
which results in sudden stopping of nail
growth. Shedding may occur with any
condition which causes severe onycholysis.
It may rarely occur with lichen planus.

8. • Onychorrhexis. The nail
separates at lunula or matrix,
and is shed partially or
completely. Causes - Psoriasis,
eczemas, pachyonichia,
nutritional upsets, systemic
illness, old age.
• Onychoschizia/Lamellar
splitting of the nail plate
occurs distally and
horizontally and is caused by
exogenous factors,
particularly repeated
immersion in water.

9. Nail changes can be classified into
• Congenital
• Infection
• In association with systemic disease
• Secondary to dermatological disease
• Neoplastic
• Traumatic.

10. Congenital abnormalities
Extremely rare
• Anonychia (complete absence of nails).
• Micro- or macronychia.
• Onycho heterotopia (abnormally
situated nail) e.g on the volar aspect of
the finger), racket nail a congenital
abnormities the thumb with the nail
conforming to the altered shape of the
thumb,
• Leukonychia totalis (Congenital
complete whitening of nails)
• periodic shedding of nails, excessive
pitting or ridging of nails.

11. Pachyonychia congenita:
it is a rare genodermatosis
Hypertrophy of the nails with
thickening, subungual hyperkeratosis
and hyper curvature of nails occurs
in Pachyonychia congenita, it is a rare
genodermatosis.Also seen in
hyperparathyroidism or vitamin D
therapy.
Racket nails:
Congenital abnormality of the
thumbs in which the distal phalanx is
shorter and wider than normal, the
hand is short and wide. (It can also
be seen in tertiary
hyperparathyroidism consequent to
bone erosion).

12. Ingrowing nail affects great toes
where the lateral portion of the nail
grows into the paronychium and this
elicits an inflammatory response with
granulation tissue.
Triangular lunula seen in nail-patella
syndrome.
Other abnormalities. Broad or square
nails occur in acromegaly.
Long and narrow nails may be
observed in hypopituitarism and
eunuchoidism. Hypoplasia and splitting
of the nail in nail-patella syndrome.

13. Paronychia
• The proximal and lateral nail folds are commonly affected by
local infection. When it occurs acutely, it usually begins at the
side of the nail with redness and swelling and pus may collect.
• The condition may present as a more chronic paronychia with
loss of cuticle overal or part of the nail with thickening of the
nail fold and variable inflammation.
• Acute paronychia usually affects one nail and is often related
to minor trauma, whereas the chronic state may affect several
nails and usually results from repeated immersion in water.
• Paronychia also occurs with psoriasis and Reiter's disease and
as a side-effect of retinoid therapy.

14. Onychomycosis (tinea unguium) . presents the
following patterns.
1. Yeasts enter the nail plate distally and the nail
plate thickens, becomes yellow and is
undermined by subungual hyperkeratosis.
2. Proximal white subungual onychomyosis may
present with a white proximal nail plate, a pattern
more common in the immunosuppressed.
3. Candida spp. is most commonly found
colonizing the damp undersurface of an
onycholytic fingemail, where warmth and
humidity are conspicuous in affected individuals.
There may also be factors influencing local or
systemic immunity (e.g- peripheral ischemia,
diabetes mellitus).
Colonization by Candida spp. differs from
genuine infection, because though the nail is
lifted from the nail bed and discolored, it is not
thickened and there is no nail bed hyperkeratosis.

15. Green Nail Syndrome
• Green discoloration due to
are produced by
pseudomonas spp. which
may be a secondar nader in
chronic paronychia or in
onycholysis, sometimes in
association wit candida
albicans Often in moist
environments
• Treat with drying measures
and topical antibiotics

16. Systemic Disease and Nail Changes
• Clubbing (pulmonary, cardiac, GI diseases)
• Koilonychia (iron deficiency anemia)
• Beau’s lines (systemic illness, chemotherapy)
• Muehrcke’s lines (hypoalbuminemia)
• Terry’s nails (cirrhosis, CHF)

17. CLUBBING
• The selective bulbous enlargement of distal
segments of fingers and toes due to
proliferation of connective tissue particularly
on the dorsal surface is termed clubbing.
• They are also called Hippocratic fingers,
serpents head deformity of fingers

18. CAUSES OF CLUBBING
RESPIRATORY CAUSES
• MALINANCIES : Bronchogenic
carcinoma, Mesothelioma
• SUPPERATIVEDISEASES:
Bronchiectasis,Lung abscess, Empyema
• INTERSTITIAL LUNG DISEASES
• TUBERCULOSIS
• SARCOIDOSIS
CARDIAC CAUSES
• Subacute bacterial endocarditis
• Atrial myxoma
• Cyanotic heart disease
• Acyanotic heart disease with
eisenmengerisation
GASTROINTESTINAL CAUSES
• INFLAMMATORY BOWEL
DISEASES:
• Ulcerative colitis
• Crohns diseases
• Primary biliary cirhhosis
• Hepatocellular carcinoma
NEUROLOGICAL CAUSES
• Synringomyelia
• Median nerve injury
• Hemiplegia

19. Koilonychia (Spoon nails)
• Concave, hollow or saucer-shaped nails, usually thin with edges
raised and centres depressed are characteristic of iron deficiency
anemia but may be seen in early infancy when it is a temporary
condition.
• They have also been observed in manual workers constantly doing oily
work, in rickshaw pullers and also in thyrotoxicosis, rheumatic fever,
ischemic heart disease, porphyria, syphilis, inherited (autosomal
dominant) and liver disease.
• Rickshaw pullers tend to get traumatic toenail koilonychia.
• Early koilonychia when it is not so pronounced, presents as brittle, flat
nails (platynachia).
• Also seen in lichen planus, repeated exposure to detergents

20. Beau's lines
Horigantal ridges due to due to severe illness (physical or
mental ) with which we can roughly estimate date of
onset of illness as it takes about 3 months for a nail to
grow completely.
• Sequella of any severe
systemic illness that
affects growth of the
nail matrix.
• When lines appear on
isolated nails the cause
is likely to be local
e.g. Raynaud's syndrome
Carpal tunnel syndrome.

21. Splinter hemorrhages (Splinter fingers).
Linear hemorrhages or hemonhagic
streaks under the nails are due to
disruption of the fine capillaries along
the dermal ridges and occur usually
along the distal end of the nail bed.
• They may exist without an obvious
cause.
• They are commonly due to
occupation trauma but are also seen
in infective endocarditis, rheumatic
fever, infectious mononucleosis,
cryoglobulinemia, severe
hypertension, severe rheumatoid
arthritis, and widespread malignancy.

22. Muehrcke’s lines
• Paired, narrow, white bands parallel
to the lunula, and separated from
one another by strips of pink nail, are
the result of hypoalbuminemia and
disappear when the serum albumin
level returns to normal.
Mees lines
• White lines or bands on the finger
nails or toe nails.
• Are sometimes found in arsenic
poisoning, in association with palmar
keratosis, in Hodgkin's disease, high
fevers or local nutritional
derangement

23. • lindsays nails Half- and-half nails
occur in chronic kidney failure
and consist of two parts
separated by a well-defined line.
The proximal area resembles
ground glass in appearance, while
the distal part is pink, reddish or
brown in colour. The half-and-half
phenomenon disappears within
2-3 weeks of successful kidney
transplantation, but is not
influenced by dialysis.

24. • In dermatomyositis, thickening, roughness, hyperkeratosis and
irregularity of cuticle are often observed. They are painful when
pushed back, and the capillary loops are massively dilated and
tortuous. These changes show alternating remission and recurrence, in
keeping with the severity and fluctuation of underlying disease activity.
• In early systemic sclerosis associated with Raynaud's phenomenon,
the dilated vessels and deformed capillary vessels around the nail fold
may be of diagnostic value. In early lupus erythematosus, the loop
appearance of the vessels has been compared to the renal glomerulus.
• Capillary pulsations in the nail bed can be observed in AR, and in
hyperdynamic circulatory states, and are best illustrated by exerting
slight pressure over the distal end of the nail.
• In jaundice If the tips of the nails have a mirror-like polish, then the
patient has an intractable dermal itching and may have obstructive
jaundice.

25. Red half-moons may be seen in congestive heart failure.
Brittle nails may be due to systemic causes such as impaired
peripheral circulation or iron deficiency anaemia, or local cause
such as constant immersion in water especially if alkaline, or use of
nail varnish or cuticle removers.
Subungual fibromata. Warty swellings arising from the lateral
edges of the nail base may be seen in tuberous sclerosis (epiloia).
Nail bed infarcts are the result of vasculitis and may be seen in SLE
and polyarteritis
Egg shell nails have been described in avitaminosis A.

26. • Hereditary haemorrhagic telangiectasia/ Nail fold telangiectasia Dilated
capillaries and erythema at nail fold seen in Connective tissue disorders, including
systemic sclerosis, systemic lupus erythematosus there are, particularly in the nail
folds or beneath the nails, small violaceous blood-filled capillaries and arterioles
which blanch on pressure.
• Median canaliform dystrophy. This curious dystrophy of unknown etiology
usually affects only one nail, typically the thumb. The deformity consists of a
central longitudinal split with bilateral depressions extending outwards from this
giving an 'inverted fir-tree' appearance. The condition clears spontaneously.
• Nails in jaundice If the tips of the nails have a mirror-like polish, then the pt has
an intractable dermal itching and may have obstructive jaundice
• Nails in impaired peripheral circulation Chronic arterial insuficiency of any cause
may lead to logitudinal rigging and thinning of the nails

27. • Discoloration of the nail may result from
abnormalities in the colour of the nail itself, or of
the colour of the subungual tissue transmitted
through the nail.
• Actual discoloration of the nail plate can be due to
exogenous or endogenous factors.
• Exogenous factors include exposure to dyes or
chemicals. In these circumstances, the discoloration
often parallels the shape of the proximal nail fold.
• Endogenous discoloration by contrast, tends to
follow the shape of the lunula, as in the case of
systemically administered drugs.

28. Yellow nails
• occur in yellow nail syndrome of
increased transverse curvature, low rate
of growth and increasing yellow
discoloration of nails seen mostly in old
men and associated with lymphatic
oedema (here it may help to distinguish
between peripheral lymphoedema and
cardiac or renal oedema)
• idiopathic pleural effusion, Bronchectasis
• chronic chest infection and myxoedema
• Prolonged tetracycline therapy may also
cause a yellowish discoloration of the
nails. The nails may have a yellowish

29. Melanonychia
Black nails.
Longitudinal melanonychia (linear pigmentation)
is a normal finding in coloured races. It is also
found in diseases characterised by abnormalities
of pigmentation, such as Addison's disease, Peutz-
Jegher’s syndrome,hemochromatosis, or as a
result of the effects of cytotoxic drugs.
• It may also be produced by malnutrition,
particularly vitamin B, deficiency.
• Longitudinal melanonychia in a single nail may
indicate an underlying malignant melanoma.
Brownish nails.
Potassium permanganate soaks turn the nails
brown, as also prolonged application of nail
vamish.
• Other causes can be melanocyte naevi, drugs
like antimalarials and zidovudine, and

30. Leuconychia
whiteness of the nails is said to be true
when it affects the nail plate, and apparent
when it affects the subungual tissues.
• A true leuconychia may be congenital or
acquired, occasionally appearing after
systemic illness such as myocardial
infarction, shock or ulcerative colitis
• Anemia gives rise to pallor with
apparent leuconychia.
• Terry's nails: Proximal 4/5th nail white
in colour with normal distal tips
encountered in cirrhosis of liver, all nails
uniformly involved The condition may
also be seen in diabetes mellitus and
cardiac failure

31. BLUE NAILS
may be seen as a side-effect of
antimalarial drugs such as
chloroquine or mepacrine used for
the treatment of lupus
erythematosus.
• Cyanosis due to hypoxia
• Blue or azure half- moons,
restricted to the lunula may be
seen in Wilson's disease from
deposition of copper. Azure
lunulae are also common in argyria
( Blue pigmentation of skin).

32. Nail Signs in Dermatologic Conditions
• Many skin diseases have nail involvement
• Nail findings may aid in diagnosis
• Longitudinal white lines are a feature of keratosis follicularis
(Darier's disease).
• PRURIC NAILS. Polished and wornout nails in individuals with
chronic pruritus seen particularly in erythroderma.
• Oly droplets in melanocytic naevi, drugs (c.g. antimalarials,
zidovudine) subungual tumors,

33. Psoriatic nail dystrophy
Nail involvement in ~50% of psoriasis
patients
Pits are small punctuate depressions
in the nail plate arranged in
haphazard or regular manner. They
are characteristic of psoriasis but
may also be found in alopecia areata
and in eczema.
Onycholysis is separation of the nail
from the nail bed. Air, debris and
exudate then come between the
two, and the pink hue of the nail bed
is no longer visible through the nail.

34. Subungual hyperkeratosis is thickening of the
nail bed with psoriatic scale that cannot be lost
because of the overlying nail. Consequently the
nail is lifted up by the crumbling yellow material
between the nail bed and plate.
oily spot is psoriasis into the nail bed.

35. Lichen Planus Longitudinal
ridging, thinning
• Pterygium formation
(scarring of nail fold to
matrix)
• May lead to nail loss
Alopecia Areata
• Nail pitting (regular and
geometric)
• Trachyonychia (rough nails)
• May occur without hair loss

36. Eczema and Atopic Dermatitis
• In individuals with atopic eczema, the nail plate can be
pitted and suffer transverse ridges even when there is no
obvious rash involving the proximal nail fold.
• When eczema involves the nail bed, there may be
subungual hyperkeratosis causing the nail to lift
• Chronic inflammation can lead to ridging
• Nail plate thinning and brittleness
• Secondary infection possible

37. Pterygium formation.
• Due to destruction of matrix, nail
plate cannot be manufactured at
the affected matrix site.
• Hence the epithelium of the
proximal nail fold attaches
directly to the nail bed
epithelium and both grow out
distally together to produce a
wing-like appearance (Pterygium
= wing).
• Causes – Lichen planus,
peripheral vascular disease,
sarcoidosis, graft-versus-host
disease, leprosy, idiopathic.

38. Nail Tumors and Malignancies
• Rare but important to recognize
• Can be benign or malignant
• May mimic benign nail conditions
Wart like changes in nail bed Invasive or in situ
cell cancer may present in a warty or scaling
change or a tumor of the nail folds which can
gradually disturb nail growth.

39. Glomus Tumor The nail bed is rich
in neurovascular glomus bodies,
which very occasionally undergo
benign enlargement to produce the
exquisitely painful glomus tumour
sometimes seen through the nail as
a small dark spot.
Squamous Cell Carcinoma (SCC)
Most common nail unit cancer
• Non-healing ulcer or warty lesion
• Often misdiagnosed as fungal
infection

40. Malignant melanoma may
occur in the nail bed either as a
pigmented lesion masquerading
as a non-pigmented friable mass
which may destroy the nail.
• Dark streak (longitudinal
melanonychia)
• Hutchinson's sign: pigment
extends to nail fold
• Requires biopsy and urgent
referral
Sungual Exostosis Present as
hard nodules, usaly on the toes,
which distort the nail.
• Bony outgrowth beneath nail
• Painful, often after trauma
• Lifts the nail plate

41. Traumatic Nail Injuries
• Common in manual workers and athletes
• Important to differentiate from disease
• Lamellar splitting of distal end of nail plate
from use of detergents and wet work
Nail Avulsion and Laceration
• Partial or full detachment from nail bed
• Risk of infection and nail deformity

42. • Longitudinal brown streaks in the nail
Subungual haematoma, benign racial
(often multiple), melanocytic naevus,
drugs (minocycline, zidovudine),
Addison’s discase, frictional (on edge
of toes or occupational on hands),
Laugier-Hunziker syndrome (multiple
benign streaks with buccal
pigmentation), fungal nail infection,
lichen planus, sqamous cell
carcinoma.
• Accumulated blood under nail due to
trauma
• Painful, dark discoloration
• May require trephination

43. Warts around the finger nails may occur in nail biters.
Habit-Tic Deformity
• Tic dystrophy - following habit of picking or rubbing cuticle
of nail causes a groove in the centre of the nail plate with
transverse ridges radiating from the groove.
• Central depression due to repetitive trauma (e.g. rubbing)
• Linear ridging on the dominant hand thumb nail, a habit-tic
deformity is due to scratching of the nail at times of stress.
Median Nail Dystrophy
• Longitudinal split or canal
• Related to trauma or tic behavior