Nail changes on different dermatologic disease
This is a education material that was used in one of the medical institute of Nepal. Prepared by Medical student
Published on: Mar 3, 2016
Transcripts - Nail changes on different dermatologic disease
Nail changes on
• 10-15% of patients with psoriasis have nail involvement.
Nail changes include
Pitting (small, regularly placed pits, as on a thimble)
Nail plate thickening (tunneled nail plate)
Subungual hyperkeratosis (accumulation of keratinous material which does
Discoloration and dystrophy of nail plate (nail plate becomes yellow or
brown and dystrophic)
Onycholysis (separation of nail plate from the nail bed)
Oil spot (due to nail bed psoriasis and is specific for psoriasis)
Thimble-like pitting of nails with onycholysis Onycholysis
• Fungal infection of nails
• Toe nails more frequently involved than finger nails
• Caused by dermatophytes (Trichophyton rubrum commonest)
• Involvement starts at distal edge and spreads proximally
• Nail plate is yellow and thick and crumbles easily (so is tunneled)
• Subungual hyperkeratosis, which is friable
Onychomycosis of toenails: distal and lateral subungual type (DLSO)
Tinea unguium: proximal subungual
onychomycosis type (PSO)
Onychomycosis of toenails:
superficial white type (SWO)
Psoriasis of nails Onychomycosis
Symmetry: symmetrical involvement of several
Asymmetrical involvement of few nails
Site: begins proximally Usually begins distally
Pitting: very frequent Not seen
Nail plate: thickened and discolored Thickened, discolored and tunneled
Subungual debris: does not crumble it is firm Friable
- Potassium hydroxide preparation of nail clippings
shows fungal hyphae
- Culture for fungus
- Systemic- Terbinafine, Itraconazole, Grsefulvin
- Topical- Amorolfine/ciclopirox
• Affects 10-50% of those with alopecia areata
• Pitting and thinning of nail plate are the most common findings
• predominantly of the fingernails
• Hammered brass appearance
• Trachonychia ( roughness caused by excessive longitudinal striations)
Alopecia areata: trachonychia The nail plate is
rough with a “hammered brass” appearance.
Nails can have dents, white spots,
• Seen in 15% of patient (less frequently in children)
• One, several, or all 20 nails may be involved (“twenty-nail syndrome,”
where there is loss of all 20 nails without any other evidence of lichen
planus elsewhere on the body).
• Thinning and distal splitting of nail plates, longitudinal ridging
• Tenting of nail plate (pup tent sign)
• Trachyonychia: characterized by nail roughness due to excessive
longitudinal ridging( sand paper nails)
• Pterygium: It is diagnostic. Proximal nail fold is prolonged on to the
nail bed, splitting and destroying the nail plate.
Middle finger: Involvement of
the proximal fold and matrix has caused
trachonychia, longitudinal ridging,
and pterygium formation.
Involvement of the nail matrix with
scarring or pterygium formation proximally
dividing the nail plate in
Early involvement of the matrix with thinning
of the thumbnail plates.
nail plate is completely destroyed, i.e.,
• Nail changes may develop with pompholyx or chronic eczema of hands and/or feet.
• Patients may have a genetic tendency to atopic eczema and/or pompholyx eczema.
• May result from outside factors such as stress, handling irritant substances, frequent
immersion in water or contact allergies.
• May occur at any age. Usually patients have a history of long-standing eczema.
• Irregular transverse ridging.
• Pitting, thickening and discolouration.
• Other signs of eczema of the hands or feet affected.
• Usually a clinical diagnosis. Investigations not usually necessary except allergy testing and
nail clippings to exclude fungal infection.
•Deformities, nail brittling,atrophic and hypertrophic changes may occure
•Spooning of nail
• FITZ PATRICK’S COLOR ATLAS AND SYNOPSIS OF CLINICAL
DERMATOLOGY SIXTH EDITION
• Dermatology by Neena Khanna