Can Ms Cause Nail Problems
Indian Dermatol Online J. 2015 Mar-Apr; 6(2): 67–74.
Nail equally a window of systemic diseases
Archana Singal
Department of Dermatology and STD, University College of Medical Sciences and Guru Teg Bahadur Hospital, Academy of Delhi, New Delhi, India
Rahul Arora
Department of Dermatology and STD, Academy College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, New Delhi, India
Abstruse
Sure nail changes are specific for diverse dermatological disorders. In addition, examination of nails may too provide an insight into more sinister systemic manifestations in the form of both subtle as well as specific changes. These findings may present as a defect of various anatomical components of the nail unit of measurement; nail matrix, nail plate and/or smash bed or vasculature. This commodity is an endeavour to equip the dermatologists with a foresight to suspect and diagnose the unapparent systemic connotations that may be possible by a simple but detailed nail test.
Keywords: Matrix, nail, blast bed, nail plate, smash unit of measurement, systemic diseases
INTRODUCTION
Subtle nail abnormalities can harbinger bloodcurdling systemic diseases. Hippocrates in the 5th century described clubbing equally an important clue to myriad of systemic manifestations.[one] Since and then many more smash findings have been institute to be associated with systemic diseases. Therefore, exam of the nails should be an integral part of a consummate dermatological examination. Clinicians must acquaint themselves with these nail findings every bit they can provide a clue in diagnosing certain systemic diseases. Moreover, at times, some nail changes can be a presenting feature before other signs of a systemic disease become clinically evident. With the convenience with which all xx nails can be examined; certainly, they serve equally an important diagnostic tool. Fingernails usually provide more accurate data than toenails, because clinical signs on toenails are often modified by trauma.
Classification
Information technology is important to classify the nail involvement in systemic diseases according to its specificity of association [Box 1].[2]
Box i
Nail changes and systemic associations
However, for a dermatologist, it is also important to classify them according to the clinical presentation, that is, morphological changes in the smash unit [Box 2]. We will discuss briefly the importance of these changes and their possible association with various systemic diseases.
Box 2
Various morphological changes in the blast unit
Abnormalities of smash shape
Koilonychia
It is the presence of reverse curvature in the transverse and longitudinal axis, giving a concave dorsal aspect to the blast. These changes result in spooning of the nails capable of retaining a drop of water. It is appreciable more than on fingernails and so toenails [Figure 1]. Koilonychia tin be idiopathic or associated with a variety of weather such as fe deficiency anemia (Plummer Vinson syndrome), malnutrition, hemochromatosis, coronary affliction, thyroid disorders, Upper gastrointestinal malignancy, traumatic injury, or occupational.[2,three] Koilonychia is of mutual occurrence in immature infants merely tend to disappear in early years of life in majority. Subungual hyperkeratosis accompanying koilonychias is suggestive of psoriasis. A number of factors, such as sometime age, digital ischemia, and so on, leading to thinning of nails may cause koilonychia. Occupational softening and iron deficiency are probably the nearly common causes.[4,5] Balmy smash-plate thickening and discoloration are also indicative of an occupational cause. The petaloid nail is an early stage of koilonychia and is characterized past flattening of the nail.[six]
Fingernails with koilonychia and trachyonychia
Hereditary and built forms are rare and are sometimes associated with other smash signs such equally leukonychia. Manual is dominant with high penetrance.
The verbal crusade of koilonychia is at best elusive. An angulation of the nail matrix secondary to connective tissue changes or spooning of the blast resulting from a relatively low distal matrix every bit compared with the proximal matrix, are some of the proposed hypotheses.[7]
Clubbing
Information technology is characterized past increased blast plate curvature longitudinally and transversely with soft tissue hypertrophy of the digital pulp usually involving all 20 digits. Clubbing has been studied extensively and rationally and forms an integral component of whatsoever general concrete examination in clinical practice. Because of an exhaustive list of systemic associations, information technology is classified into three major categories: Idiopathic, hereditary–congenital, and acquired.[6,seven] It may take connotations with systemic diseases, such as cyanotic congenital heart diseases, infective endocarditis, primary and metastatic lung cancer, bronchiectasis, lung abscess, cystic fibrosis, mesothelioma, inflammatory bowel disease, and hepatic cirrhosis.[eight,nine]
Clubbing may exist an early on sign of AIDS in pediatric HIV-positive patients. Information technology may be associated with hypertrophic osteoarthropathy, in which subperiosteal new os formation in the distal diaphysis of the long basic of the extremities causes pain and symmetric arthritis-like changes in the shoulders, knees, ankles, wrists, and elbows.
Three forms of geometric assessment can be performed in clubbing. (ane) Lovibond'south angle at the junction between nail plate and proximal blast fold and it is normally less than 160°. In clubbing, this is increased to over 180°. (2) Curth'south angle at distal interphalangeal (DIP) joint is normally approximately 180° and this diminishes to less than 160° in clubbing [Figure 2]. (3) Schamroth sign refers to the obliteration of usually diamond-shaped infinite formed when dorsal sides of the distal phalanges of corresponding right and left digits are opposed [Figure 3].[10]
Lovibond'south angle and Curth'southward angle in patients with clubbing
A diamond-shaped Schmaroth's window present commonly is obliterated in patients with clubbing
Pincer nail
When the transverse curvature of the blast is increased along the longitudinal axis of the blast reaching to its greatest proportion toward the tip, information technology is called pincer nails. An association with a curved ingrown blast with bilateral penetration to the smash folds is non uncommon. Pincer nail may be hereditary or caused. Although the mechanism of its development remains unknown, underlying systemic illness or medications are the common associations. The dorsal extension of os acquired by a subungual exostosis may besides produce the pincer nail; hence the nail equally well as the exostosis must be excised. The lateral borders of the nail exert a constant pressure, permanently constricting the deformed nail plate (unguis constringens). Moreover, a few reports suggest an onychomatricoma may present with a pincer nail. In addition, Kirkland and Sheth reported a case of caused pincer nail deformity associated with end-stage renal disease secondary to diabetes mellitus.[4,11]
Dolichonychia
It is defined as the length of nails greatly exceeding the width of blast and has been associated with Marfan's syndrome and hypopituitarism.[12]
Brachyonychia
In brachyonychia, the width of the boom plate is reduced equally compared to the length. It may exist a characteristic of hyperparathyroidism and psoriatic arthropathy as an early sign of bone resorption.[10,13]
Parrot beak nail
A symmetrical overcurvature of the free edge of finger nails mimics the nib of a parrot. Information technology is typically seen in astringent acrosclerosis with distal phalangeal resorption due to scleroderma. The blast plate may bend effectually the shortened fingertip.[4,14]
Macronychia and micronychia
These constitute nails that are too large or too pocket-size compared with other nails on nearby digits. Macronychia may be due to local gigantism, whereas micronychia may occur in association with plexiform neuromas.[10]
Abnormalities of nail zipper
Onycholysis
Onycholysis refers to the distal separation of the nail plate from the smash bed [Figure 4]. Areas of separation appear white or yellow due to air beneath the nail and sequestered droppings. Information technology is more frequently associated with diverse local conditions such as trauma, psoriasis, fungus, and contact irritant reactions (boom cosmetics) than systemic disease. The correlation of onycholysis with the systemic diseases appears to be over-rated. Systemic associations include anemia, brochiectasis, lung cancer, cutaneous T-cell leukemia, diabetes mellitus, thyroid disorders, porphyria, lupus erythematosus, psoriatic arthritis, Sezary syndrome, drugs (psoralens and tetracyclines), and Vitamin C deficiency.[15,sixteen] When information technology happens in thyrotoxicosis, the primeval stage is conversion of the curved adhesion line to a straight line. This adhesion line later dips proximally into the nail bed every bit a jagged project. This description is that of Plummer's nails, which usually involves fourth and fifth fingers.[ii]
Onycholysis of fingernails in a patient with thyroid disorder
Pterygium
Pterygium unguis [Effigy 5] results from a scarring involving the nail fold extending onto the matrix. It may be a "dorsal pterygium" where proximal nail fold fuses to matrix and later to boom bed or "ventral pterygium" where a distal extension of the hyponychium attaches to the undersurface of the nail plate thereby obliterating the distal nail groove. Dorsal pterygium is classically seen in lichen planus. It may also be seen in burns, cicatricial pemphigoid, dyskeratosis congenital, graft versus host affliction, radiodermatitis, and lupus erythematosus. Also, ventral pterygium is seen in leprosy, neurofibromatosis, subungual exostosis, lupus erythematosus, and systemic sclerosis.[4,17]
Pterygium in second and third fingernails in lichen planus
Abnormalities of nail surface
Longitudinal ridging (Onychorrhexis)
Longitudinal lines, or striations, may appear as indented grooves or projecting ridges and may represent long-lasting abnormalities [Effigy 6]. Although a unmarried nail crevice is about likely due to a minor trauma, systemic connotations have been found with systemic amyloidosis, nail-patella syndrome, collagen vascular diseases, graft versus host disease, and rheumatoid arthritis.[4,10]
Longitudinal ridging with beading and fissuring associated with severe anemia
Cardinal ridges can also be caused by iron, folic acid, or protein deficiency.
Beau's lines
Described first in 1846, Beau'southward lines are ring-similar depressions extending from one lateral edge of the boom to the other. Information technology is the well-nigh common and least specific blast change in a systemic disease. Its exact crusade is not known but there is temporary abeyance of nail growth in the matrix by diverse factors, for example, trauma involving proximal nail fold, severe astute affliction such as fever, middle attack, exposure to extreme cold, psychological stress, and poor nutritional status. Idiopathic and inherited forms too occur. If in that location is consummate inhibition of smash growth for around 2 weeks, Boyfriend'south line will attain maximum depth resulting in onychomadesis [Figure seven]. Recurrent bouts of disease may pb to the germination of series of transverse furrows/grooves [Figure 7]. The width of the transverse groove relates to the duration of the affliction that has affected the matrix. The distal limit of the furrow, if precipitous, indicates a sudden attack of disease; if sloping, a more protracted onset.[xviii] The presence of Beau's lines on all 20 nails is usually the effect of systemic disease such every bit mumps, pneumonia, coronary thrombosis, Kawasaki disease, syphilis, and hypoparathyroidism.[iv,10]
Multiple Beau's lines in the middle finger and onychomadesis in the index finger
Nail pitting/trachyonychia
Pits upshot from a defective keratinization of the proximal matrix with persistence of parakeratotic cells in the nail plate surface.[19] Its part and diagnostic utility is hundred-to-one every bit a large number of local factors impact the matrix function. It may occasionally be useful in diseases such as psoriasis, psoriatic arthritis [Figure eight], SLE, dermatomyositis, syphilis, sarcoidosis, and pemphigus vulgaris.[2,xix,20]
Trachyonychia in a patient with psoriatic arthritis without skin lesions
Onychochizia
Horizontal splitting of nail toward its distal portion is also called lamellar splitting of nail. Although trauma is the well-nigh common cause, information technology has been reported with X-linked chondrodysplasia punctata, polycythemia vera, and systemic retinoid therapy.[four,21]
Abnormalities of nail color
Leukonychia
Leukonychia refers to the white discoloration of nail. Information technology is traditionally classified into three subtypes.[22]
Truthful, when pathology originates in matrix and emerges in the nail plate.
Apparent, when pathology is in the smash bed.
Pseudo, when nail plate pathology is exogenous, for example, onychomycosis [Figure nine].
Superficial white onychomycosis
Leukonychia associated with systemic disease is usually true or apparent
-
Mees lines: True leukonychia due to arsenic intoxication is characterized by a single or multiple, transverse, narrow whitish line running along the width of the blast and parallel to lunula, and may involve multiple nails. These lines practise not disappear on blanching and move distally with time.[23,24] Histology shows fragmented nail plated with foci of parakeratotic cells. They have been reported with other weather likewise such every bit Hodgkin'south disease, leprosy, tuberculosis, malaria, herpes zoster, chemotherapeutic drugs, carbon monoxide (CO) and antimony poisoning, renal and cardiac failure, pneumonia, and childbirth.
-
Muehrcke'due south lines: These are apparent leukonychia characterized by double white transverse line [Figure 10], resulting maybe from a localized edematous state in the nail bed exerting force per unit area on the vascular bed. They are specific for hypoalbuminic state (occur in patients albumin <ii g/dL) and disappear when the protein level normalizes. Muehrcke's lines are seen in nephrotic syndrome, glomerulonephritis, liver disease, chemotherapeutic drugs, and malnutrition.[22,25,26]
Muehrcke's lines in a patient with stop-stage renal disease with hypoalbuminemia of <two gm%
-
Half and half nail or Lindsay blast: Apparent leukonychia with a normal proximal half and abnormal brown discolored distal half [Figure eleven]. It is seen in patients of chronic kidney disease with uremic renal failure.[26,27]
One-half and one-half nails in a patient with chronic kidney disease
-
Terry nails: Credible leukonychia with nail that is white proximally and normal distally [Effigy 12]. It is associated with congestive cardiac failure, adult-onset diabetes mellitus, peripheral vascular disease, hemodialysis, and HIV.[27,28]
Terry'south nails in a patient with congestive heart failure
Melanonychia
A longitudinal or transverse dark-brown blackness pigmentation of nail has been typically attributed to lichen planus commonly seen in our clinics. Melanonychia may exist office of being racial pigmentation (constitutional). However, an underlying melanocytic nevus or malignant melanoma, drugs (antimalarials, minocycline, phenytoin, psoralens, sulfonamides, zidovudine, doxorubicin, methotrexate, azathioprine, and so on), hemochromatosis, malnutrition, thyroid affliction, smoking, HIV infection [Figure 13], and Addison'due south disease can nowadays similarly.[4,29]
Diffuse melanonychia involving all nails in a HIV+ve patient
Cyanosis
Cyanosis may manifest every bit blue or purple discoloration of the nail bed and digits equally a result of lower oxygen saturation causing accumulation of deoxyhemoglobin in the small blood vessels of the extremities. Central cyanosis is caused by congenital center diseases and may manifest on mucosa and extremities, whereas peripheral cyanosis is usually diagnosed by examination of the blast and digits and is caused by vasoconstriction and macerated peripheral blood flow every bit occurs in cold exposure, shock, congestive cardiac failure, and peripheral vascular disease.[ten]
Icterus
Xanthous discoloration of the mucosae as a result of deposition of bilirubin may extend to involve the nails in severe cases and may represent severe grade of liver disease or hemolysis.[10]
Nicotine staining of nails
Heavy smokers may develop a yellow discoloration of nail due to nicotine deposition. The discoloration may be a tell tale sign of long-term chances of development of cigarette-associated diseases such every bit carcinoma lung, chronic obstructive airway disease, and coronary avenue affliction.[ten,30]
Splinter hemorrhages
Splinter hemorrhages in nails are formed by the extravasation of blood from the longitudinally oriented vessels of the nail bed. They occur commonly in psoriasis but may exist seen in the setting of infective endocarditis [Figure 14], rheumatic center disease, valvular replacement, SLE, antiphospholipid syndrome, 4 drug abusers, and built middle diseases. A simultaneous occurrence in multiple nails is indicative of a systemic cause.[2,22,31]
Splinter hemorrhage with bacterial endocarditis
Xanthous nail syndrome
It is characterized by thickening and yellow to yellow-dark-green discoloration of the nails oftentimes associated with systemic disease, nigh unremarkably lymphedema and compromised respiration due to pleural effusion [Figure 15]. The condition unremarkably occurs in adults just may occur in childhood. The lunula is obscured and there is increased transverse and longitudinal curvature with loss of cuticle.[10,32]
Yellow discoloration of all smash syndrome
Cerise lunula
Ruby lunulae are seen in collagen vascular affliction, cardiac failure, chronic obstructive pulmonary illness (COPD), cirrhosis, chronic urticaria, psoriasis, and CO poisoning[33] Information technology may merge with the nail bed in the distal part of the lunula or be demarcated by a pale line and tin be obliterated past pressure level on the nail plate.[10]
Nail bed telangiectasia
Periungual telangiectasia is an important clue to systemic involvement in systemic sclerosis, SLE [Figure 16], and dermatomyositis influencing the prognosis of the illness. Furthermore, they may also be seen in diabetes mellitus, COPD, and rheumatoid arthritis.[2,34]
Nail bed telangiectasia in a patient with disseminated lupus erythematosus
Nail abnormalities in specific organ organisation
Tabular array 1 depicts smash involvement associated with certain specific organ systems. Although overlap in findings is mutual, subtle changes may predict sinister internal involvement.[22]
Table 1
Nail manifestation specific to organ system involvement
Nail involvement in genodermatosis
Genodermatosis may present with a constellation of signs and symptoms thereby clinching the diagnosis. Nevertheless, many times subtle only characteristic findings in nails bring us very close to the diagnosis itself. Table 2 depicts genodermatosis associated with blast involvement.[22,35]
Tabular array ii
Nail manifestations in genodermatoses
Hence, blast findings may not only exist window to a plethora of possible systemic associations, but also a window of opportunity as a profound knowledge of the associations may be useful in a consummate and targeted workup of the patient to pre-empt the clinching of a more than sinister systemic disease.
Footnotes
Source of Support: Nil
Conflict of Interest: None alleged.
REFERENCES
1. Myers KA, Farquhar DR. The rational clinical examination. Does this patient have clubbing? JAMA. 2001;286:341–vii. [PubMed] [Google Scholar]
2. Lawry Yard, Daniel CR., 3rd . Nails in systemic disease. In: Scher RK, Daniel CR, editors. Nails: Diagnosis, Therapy, Surgery. 3rd ed. Philadelphia: Elsevier Science Limited; 2005. pp. 147–69. [Google Scholar]
4. Baran R, Dawber RP, Haneke E, Tosti A, Bristow I. Martin Dunitz. third ed. 2005. Nail configuration abnormalities. A Text Atlas of Smash Disorders: Techniques in Investigation and Diagnosis; pp. xviii–24. [Google Scholar]
5. Bentley-Phillips B, Bayles MA. Occupational koilonychia of the toe nails. Br J Dermatol. 1971;85:140–4. [PubMed] [Google Scholar]
vi. Stone OJ. Spoon nails and clubbing. Cutis. 1975;16:235–41. [Google Scholar]
seven. Stone OJ. Diseases of blast and their management. Cutis. 1975;sixteen:235. [Google Scholar]
8. Braunwald E. Hypoxia and cyanosis. In: Kasper DL, Braunwald E, Fauci Equally, Hauser SL, Longo DL, Jameson JL, editors. Harrison Principles of Internal Medicine. 16th ed. New York: McGraw-Hill; 2009. pp. 209–12. [Google Scholar]
9. Hansen-Flaschen J, Nordberg J. Clubbing and hypertrophic osteoarthropathy. Clin Chest Med. 1987;viii:287–98. [PubMed] [Google Scholar]
10. Motswaledi MH, Mayayise MC. Nail changes in systemic diseases. SA Fam Pract. 2010;52:409–13. [Google Scholar]
11. Kirkland CR, Sheth P. Caused pincer blast deformity associated with end phase renal disease secondary to diabetes. Dermatol Online J. 2009;15:17. [PubMed] [Google Scholar]
12. Cohen PR, Milewicz DM. Dolichonychia in women with Marfan syndrome. South Med J. 2004;97:354–eight. [PubMed] [Google Scholar]
13. Rasi A, Soltani-Arabshahi R, Naraghi ZS. Confining juvenile-onset pityriasis rubra pilaris with hypoparathyroidism and brachyonychia. Cutis. 2006;77:218–22. [PubMed] [Google Scholar]
14. Desai T, Magdum A, Patel T, Loghdey South. Parrot-beak nails. Clin Exp Dermatol. 2011;36:208–9. [PubMed] [Google Scholar]
15. Zaic MN, Daniel CR. Nails in systemic illness. Dermatologic Therapy. 2002;15:99–106. [Google Scholar]
16. Daniel CR., 3rd Onycholysis: An overview. Semi Dermatol. 1991;10:34–xl. [PubMed] [Google Scholar]
17. Richert BJ, Patki A, Baran RL. Pterygium of the nail. Cutis. 2000;66:343–6. [PubMed] [Google Scholar]
18. Yassin MA, Alhijji IA, Elayoubi Hour, Abbodi KR. Beaus lines. Saudi Med J. 2007;28:1922–3. [PubMed] [Google Scholar]
19. Jadhav VM, Mahajan PM, Mhaske CB. Smash pitting and onycholysis. Indian J Dermatol Venereol Leprol. 2009;75:631–three. [PubMed] [Google Scholar]
20. Singh SK. Finger nail pitting in psoriasis and its relation with different variables. Indian J Dermatol. 2013;58:310–2. [PMC complimentary article] [PubMed] [Google Scholar]
21. Baran R. Therapeutic assessment and side-effects of the effluvious retinoid on the boom apparatus. Ann Dermatol Venereol. 1982;109:367–71. [PubMed] [Google Scholar]
22. Singh Thou. Nails in systemic disease. Indian J Dermatol Venereol Leprol. 2011;77:646–51. [PubMed] [Google Scholar]
23. Daniel CR, third, Osment LS. Nail pigmentation abnormalities. Their importance and proper test. Cutis. 1980;25:595–607. [PubMed] [Google Scholar]
24. Chesnut K, Taylor S, Belin E. Mees lines and Beau lines. Cutis. 2013;91(150):147–1. [PubMed] [Google Scholar]
25. Gregoriou Southward, Argyriou G, Larios K, Rigopoulos D. Smash disorders and systemic disease: What the nails tell us. J Fam Pract. 2008;57:509–xiv. [PubMed] [Google Scholar]
26. Goodman GJ, Nicolopoulos J, Howard A. Diseases of the generative nail apparatus. Part Ii: Boom bed. Australas J Dermatol. 2002;43:157–70. [PubMed] [Google Scholar]
27. Tosti A, Daniel CR, tertiary, Piraccini BM, Iorizzo Thousand. Heidelberg: Springer Verlag; 2010. Color Atlas of Nails; p. 3. [Google Scholar]
28. Saray Y, Seçkin D, Güleç AT, Akgün S, Haberal M. Nail disorders in hemodialysis patients and renal transplant recipients: A case-control study. J Am Acad Dermatol. 2004;50:197–202. [PubMed] [Google Scholar]
29. Mendiratta 5, Jain A. Boom dyschromias. Indian J Dermatol Venereol Leprol. 2011;77:652–viii. [PubMed] [Google Scholar]
xxx. Verghese A, Krish M, Howe D, Stonecipher M. The harlequin nail. A mark for smoking cessation. Breast. 1990;97:236–viii. [PubMed] [Google Scholar]
31. Monk BE. The prevalence of splinter haemorrhages. Br J Dermatol. 1980;103:183–5. [PubMed] [Google Scholar]
33. Cohen PR. Red lunulae: Case written report and literature review. J Am Acad Dermatol. 1992;26:292–4. [PubMed] [Google Scholar]
34. Lin KM, Cheng TT, Chen CJ. Clinical Applications of Nailfold Capillaroscopy in Unlike Rheumatic Diseases. [Last accessed on 2014 May 17]. Available from: http://www.tsim.org.tw/journal/jour20-iii/07.PDF .
35. Inamadar Air-conditioning, Palit A. Nails: Diagnostic clue to genodermatoses. Indian J Dermatol Venereol Leprol. 2012;78:271–8. [PubMed] [Google Scholar]
Articles from Indian Dermatology Online Journal are provided hither courtesy of Wolters Kluwer -- Medknow Publications
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375768/
Posted by: vinsonarmet1952.blogspot.com
0 Response to "Can Ms Cause Nail Problems"
Post a Comment