CASE CONFERENCE:
Nail Disorders
KAREN ESTRELLA
05/12/2010
Do you check the nails of your
patients?
History
3y/o M seen at
SBC for 1st WCC
-no acute
concerns except
for: changes in
nail bed of left 2nd
nail for 1 year
Normal nail
• EMBRIOLOGY:
– starts to develop at 10-11 wks
– keratinizes from 15 wk
– fully formed by birth
Normal nail
• ANATOMY:
Consult DERMATOLOGY:
• Dark linear, uniform,
well demarcated linear
ban along the nail bed,
involving proximal nail
fold
Melanonichia
striata
What is melanonychia?
• Tan, brown or black pigmentation from the
proximal nail fold and cuticle to the free distal
end of the nail plate
– Usually affects 1 or 2 digits
• Due to: melanocyte activation (physiologic),
benign melanocyte hyperplasia (nevi), or
melanoma.
• Most common in african-american or
hispanics
Melanonychia etiology: benign
• LOCAL
–
–
–
–
–
Trauma
Radiation
Nail bitting
Foreign body
Infection
Single bands
• SYSTEMIC
– Addison, Cushing,
Hyperthyroidism,
– Hemosiderosis
– Alcaptonuria
– Psoriasis
– LES, scleroderma
– Malnutrition
Multiple bands
Melanonychia etiology: iatrogenic
• CHEMOTHERAPY
–
–
–
–
–
Metotrexatem
Bleomycin
Doxorubicin
Ciclophosphamide
5-fluoruracil
• OTHERS
–
–
–
–
–
Steroids,
Ibuprofen
Phenytoin
Zidovudine, lamivudine
Ketokonazole,
fluconazole
Melanonychia etiology: malignancy
•
•
•
•
Age: adults
Brown-black band greater than 3 mm
Change in nail band morphology despite treatment
Digit involved: The thumb is more likely to be affected
by subungual melanoma than the great toe; the great
toe is more likely than the index finger to be affected
by subungual melanoma.
• Extension onto the adjacent cuticle and proximal
and/or lateral nail folds (Hutchinson sign)
• Family or personal history of dysplastic nevus or
melanoma
Melanonychia work-up
• Dermatoscopic evaluation:
– Of the free edge of nail bed
Melanonychia:
Dermatoscopic evaluation continued
Melanonychia: work-up continued
• Nail bed Sampling:
– Punch bx: 3mm, from proximal matrix
• Risk of permanent nail dystrophy
– Nail-shave bx : 4-6mm, central portion of nail bed
– lateral-longitudinal
– If suspicion for subungueal melanoma: full
thickness
Melanonychia Treatment
• Tx of underlying condition
• Removal of agent
• If melanoma: complete removal of
hyperpigmented section
OTHER NAIL DISORDERS
Congenital disorders:
(Ectodermal defects)
• ANONYCHIA
– Associated with nail-patella
sd., deafness
• PACHONYCHIA
– Associated with:
hyperhidrosis,
leukokeratosis: TM, cornea,
mucosas
Congenital disorders continued
• HYPOPLASTIC
– Phenytoin
– Warfarin
– Fetal alcohol
syndrome
Associated with systemic disorders
• CLUBBING
– hypoxic stages
• KOILONYCHIA (spoon
nails)
– Iron deficiency
Associated with systemic disorders
• SPLINTER
HEMORRHAGES
• HALF & HALF NAILS
– endocarditis
• RIDGING-TRANSVERSE LINES
- malnourishment
– liver, kidney failure
Acquired nail disorders: infection
• PARONYCHIA
– Red, tender, swelling of
prox or lateral fold
• Acute: S. aureus
• Chronic: Candida
albincans
• ONYCHOMYCOSIS
- yellowish, brittle
- Unusual before
puberty
- Systemic antifungal tx
Acquired nail disorders: dystrophy
(distortion, discoloration)
• TRAUMA
– Subungual hematoma
• PSORIASIS
Acquired nail disorders: dystrophy
continued
• TRACHYONYCHIA
(Twenty nail dystrophy)
– School children
– Yellow or gray color
nails, (+) pitting, friable
– Progresses in 6-18
months, self-limited
– Some cases associated
with alopecia areata,
atopic dermatitis
Thank you : )
References
•
•
•
•
Cohen, B. pediatric Dermatology. Mosby LTD, Spain: 1999. pg 201-208
www.dermaimaging.com/?cat=39
http://www.ncbi.nlm.nih.gov/pubmed/10411404
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S036505962009000200013&lng=en&nrm=iso>. ISSN 0365-0596. doi:
10.1590/S0365-05962009000200013.
• http://emedicine.medscape.com/article/1375850-overview
• http://www.medscape.com/viewarticle/718695_7