nail signs

1. NAIL ANATOMY AND ITS
DISORDERS
Presenter :Dr ROHINI SONI
Moderator: Dr PASCHAL D’SOUZA

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 produced by nail matrix
(2) intermediate nail plate
(3)ventral nail plate produced by nail bed
 Thickness:1.65 ± 0.43 mm in men and 1.38 ±0.20 mm in
women.
 Fingernails are thinner; the mean thickness is 0.6 mm in men
and 0.5 mm in women.

4.  Onychocorneal Band it
is a thin distal transverse
white band.
 Marks the most distal
portion of firm attachment
of the nail plate to the nail
bed.
 Onychodermal Band: it is
a 1mm-1.5 mm pink band
present below
onychocorneal band.

5. 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.

6. 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.

7. 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(LUNULA) – It
forms ventral nail plate.
 Following cells are present in nail
matrix.
1. NAIL MATRIX KERATINOCYTES
2. MELANOCYTES
3. LANGERHANS CELLS.
4. MERKEL CELLS

8. Nail bed
 Soft tissue upon which the nail rest.
 Extends from the distal margin of the lunula to
the isthmus.
 The nail bed epithelium is so adherent to the
nail plate that it remains attached to the
undersurface of the nail when the latter is
avulsed.

9. Nail growth
 The nail plate grows continuously in a proximal to
distal manner throughout life.
 Growth rate of nails in adults :
1. 3.5 mm/month for fingernail
2. 1.5 mm/month for toenails.
 Complete replacement of a fingernail requires 100–
180 days (6 months).
 The total regeneration time for a toenail is 12–18
months.

10. Embryology
 The nail apparatus develops during the 9th embryonic week
from the epidermis of the dorsal tip of the digit as a
rectangular area, the nail fold that is delineated by a
continuous groove.
 The proximal border of the nail fold extends downward and
proximally into the dermis to form the nail matrix primordium.
 the 15th week the nail matrix is completely developed and
starts to produce the nail plate, which will continue to grow
until death.
 The nail apparatus lies immediately above the periosteum of
the distal phalanx.

11. NAIL SIGNS AS A FUNCTION
OF
THE SITE OF PATHOLOGY

13. 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
proximalnail fold by a whole-
thickness sulcus.
 Result from a temporary
arrest of proximal nail matrix
proliferation

15. 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.

16. Types of pitting
 Irregular pitting: - seen in psoriasis. Usually shallow and
small (< 1 mm).
 Geometric pitting: - multiple small superficial pits, which are
regularly distributed in a geometric pattern along longitudinal
or transverse lines. Seen in alopecia areata.
 Coarse pitting and cross ridging: - very irregular pits seen in
eczematous dermatitis.
 Elkonyxis: - very large pits, seen in syphilis, Reiters disease,
after trauma, and after etretinate and isotretinoin therapy.
 Rosenaus depression: - small pitted craters found on the
middle and ring finger and are reported to occur in diabetes
mellitus.

17. 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 etc

18. 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

20. TRACHYONYCHIA
 Twenty-nail dystrophy or
sandpaper nail
 Diffuse homogenous nail
roughness
 Often associated with
thinning
 Causes are
1.Alopecia areata
(commonly)
2.Lichen planus(rare)
3.Psoriasis
4.Eczema
Sand paper nails due to excessive
longitudinal ridging

21. 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
 Leukonychia punctata
 Longitudinal leukonychia
 Transverse leukonychia

22. Leukonychia totalis
Punctate leukonychia

23. APPARENT LEUKONYCHIA:The nails are pale white due to nail bed
discoloration that fades with pressure.

24. 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
 Pathologic
1.Iron deficiency anemia
2.Psoriasis
3.Pellagra
4.Lichen planus

25. Charcteristic spooning of nail

26. MELANONYCHIA
 Brown to black color of the nail due to the
presence of melanin in the nail plate.
 Caused by activation or proliferation (benign or
malignant) of nail matrix melanocytes.
 Types
1. Total melanonychia
2. Transverse melanonychia(rarest)
3. Longitudnal melanonychia (most common)

28. Longitudnal melanonychia

29. 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

30. Onycholysis with subungual hyperkeratosis Plummer nails

31. Infections of nails

32. 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.

33.  The proximal nail fold is painful,
erythematous, and swollen.
 Pus may be discharged after
pressure.
 D/Ds
 herpes simplex virus infection
 Hallopeau’s acrodermatitis
 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.
 Oral antibiotics such as
cephalexin, amoxicillin with
clavulanic acid, and clindamycin,
are effective

34. 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.

35. 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
• Administration of systemic antibiotics
is
unnecessary

36. ONYCHOMYCOSIS
 Fungal infection of nail unit.
 Greater frequency in patient with
AIDS,diabetes and immunosuppression.

37. Distal subungual onychomycosis Proximal subungual
onychomycosis
White superficial onychomycosis

38.  The cure rate for toenail onychomycosis is
approximately 80% with the use of systemic
antifungals.
 Recurrences are frequent (up to 20%).
 Mold infections respond poorly to systemic
treatment.

39. 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.

40. Skin diseases with specific nail
changes

41. Nail Psoriasis
 Psoriasis is a chronic inflammatory skin disease
characterized by T-cell-mediated
hyperproliferation 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 HLA Cw6 .

42. Signs in nail psoriasis

43. Clinical features
 Pitting is the
commonest
manifestation of nail
psoriasis.
 Pits affect the
fingernails more
commonly than the
toenails.
 Coarse pits are
common in psoriasis.

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

45. NAPSI CALCULATION
Estimation of NAPSI-the affected nail is divided into four quadrants and the
presence of lesions of the nail matrix (M) and nail bed (B) are given a score of
1 in each quadrant.Total maximum score of 8 and a minimum score of 0 per
nail.

46.  Systemic treatments for skin and joint
psoriasis are generally effective for nail
psoriasis (methotrexate, cyclosporine.
 In biologics infliximab 5 mg/kg appears to be
the most effective to date.
 Intralesional steroids (triamcinolone acetonide
2.5–5.0 mg/mL in saline) are the best
treatment for nail matrix psoriasis.

47. 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
sequela.
 Diagnosis should be confirmed by nail biopsy.

48. Pterygium typical of lichen planus

49. Nail matrix lichen planus: note longitudinal
ridging and fissuring of the nail plate

50.  Nail matrix lichen planus requires oral or
intramuscular treatment with systemic steroids,
which induce remission of the disease in 2/3 of
the cases.
 Intralesional (vs. systemic) corticosteroid
injections should be considered in patients
with involvement of fewer than three digits.
 Dorsal pterygium is not reversible and when it
is thesole manifestation, should not be treated.

51. 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.

52. NAIL SIGNS OF SYSTEMIC
DISEASES

54. Terry nails
•Proximal white nail with
narrow distal pink or brown
band 0.5 to 2mm
•Causes:
1. Cirrhosis
2. CHF
3. Diabetes
4. Cancer
5. Ageing
6. Hyperthyroidism
7. Malnutrition

55. 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.

56. 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.

58. TRAUMATIC NAIL
DISORDERS

59. 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.

60. Pincer nails
 Pinching of nail bed
due to over-curved
nail plate
 Congenital or due to
ill fitting footwear
 it causes severe
pain.
 Also known as
trumpet nail , omega
nail.

61.  Cause:
1. Incorrect nail care (cutting / too much pedicure)
2. Improper fitting of shoes
3. Aging (pincer nail develops mostly in the elderly)
4. Health disorders that can affect nail health (liver
problems, diabetes, malnutrition)
5. Can be a complication from an underlying diseases
such as degenerative arthritis
 surgery is the only possible treatmentfor a severe
pincer nail.
 in early stages, corrective filling and proper nail care
can be enough to maintain a healthy nail or delay
pincer nail development.

62. 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.

63.  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.

64. 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.

65. Agnail or hang nail
 Hang nail is most commonly seen in nail
biters.
 It consist of small portion of horny epidermis
breaking away from the lateral nail fold.
 The split become very painful when the
penetrate to the underlying dermis.
 Usually caused by dry skin or (in the case of
fingernails) nail biting.
 May be prevented with proper moisturization
of the skin.

66. HEREDITARY AND
CONGENITAL
NAIL DISORDERS

67. 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
duringinfancy to early childhood.

68. PACHYONYCHIA CONGENITA

69.  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.

70. 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.

72. Congenital malalignment of hallux

73. MALIGNANT TUMORS OF
NAILS

74. 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.

75.  (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.

76.  Surgical excision with Mohs surgery is the best
treatment for squamous cell carcinoma without
bone involvement.

77. 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 of
LM, usually dark in color and with irregular border.

78.  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
of LM showing suspicious
features.
 Up to 33% of subungual
melanomas are
amelanotic, and they are
often misdiagnosed as
pyogenic granuloma or
squamous cell carcinoma.

79. Thank you