NAIL APPARATUS Nails (Fig. 7.18) are homologous with the cornified layer of the general epidermis.

They consist of compacted, anucleate, keratin-filled squames in two or three horizontal layers. Ultrastructurally, the squames contain closely packed filaments which lie transversely to the direction of proximodistal growth, and are embedded in a dense protein matrix. Unlike the general epidermis, squames are not shed from the nail plate surface. A variety of mineral elements are present in nail, including calcium. Calcium is not responsible for the hardness of nail: this is determined by the arrangement and cohesion of the layers of squames, and their internal fibres. The water content of nail is low, but nail is 10 times more permeable to water than the general epidermis. The softness and elasticity of the nail plate is related to its degree of hydration.

Fig. 7.18 The organization and terminology of the structures associated with a fingernail. (By permission from Paus R, Peker S 2003 Biology of hair and nails. In: Bolognia JL, Jorizzo JL, Rapini RP (eds) Dermatology. London: Mosby.)

The nail apparatus consists of the nail plate, proximal and lateral nail folds, nail matrix, nail bed and hyponychium. Nail plate The nail plate is embedded within the proximal and lateral nail folds. It is approximately rectangular in shape and is mostly convex in both longitudinal and transverse axes: there is considerable inter- and intra-individual variation (Fig. 7.18). The thickness of the plate increases proximodistally from about 0.7 mm to 1.6 mm: the terminal thickness varies between individuals. The surface of the nail plate may show fine longitudinal ridges, and its undersurface is grooved by corresponding ridges in the nail bed. Disturbances of growth pattern or disease may lead to transverse ridging or grooves, and minute trapped air bubbles may produce white flecks. These defects move distally with growth of the plate. The nail plate arises from compacted cornified epithelial cells derived from the dorsal, intermediate and ventral nail matrices. It is densely adherent to the

matrices on its undersurface, but becomes a free structure distal to the onychodermal band, where it separates from the nail bed. The dorsal aspect of the nail plate originates from the more proximal regions of the germinal matrix, i.e. dorsal and intermediate matrices, whereas the deeper, volar aspect of the plate originates from the ventral matrix. Nail folds The sides of the nail plate are bordered by lateral nail folds which are continuous with the proximal fold (Fig. 7.18). The lateral nail folds enclose the lateral free edges of the nail plate and are bounded by the attachment of the skin to the lateral aspect of the distal phalanx margin and the lateral nail. The proximal nail fold provides the visible proximal border to the nail apparatus. It consists of two epidermal layers, superficial and deep, separated by a core of dermis. The epidermis of the superficial layer lacks hair follicles and epidermal ridges: its cornified distal margin extends over the nail plate for a little distance as the cuticle or eponychium. The deep layer merges with the nail matrix. The eponychium is bounded by the fascial attachment of the skin to the base of the distal phalanx, distal to the insertion of the extensor tendon, and its distal free edge. It adheres to the dorsal aspect of the nail plate and overlies the root of the nail. Nail matrix The nail matrix is the main source of the nail plate, and it can be divided into three parts. Proximally, the dorsal matrix is defined as the volar surface (undersurface) of the proximal nail fold. The intermediate matrix (germinal matrix) starts where the dorsal matrix folds back on itself and extends as far as the distal portion of the lunule. The ventral matrix (sterile matrix) is the remainder of the nail bed: it starts at the distal border of the lunule and ends at the hyponychium. The matrix epithelium consists of typical basal and prickle cell layer keratinocytes, among which are scattered melanocytes and Langerhans cells. Cornified cells of the dorsal and ventral aspects of the matrix are steadily extruded distally to form the nail plate: the proximal 50% of the nail matrix contributes 80% of the nail plate. This process continues into the nail bed at the distal edge of the lunule, which is formed where the distal portion of the ventral matrix underlies the nail plate.

The lunule is pale, opaque and convex and is more prominent in the thumb than the other digits. It is not known why the lunule is so pale compared with the more distal translucent pink nail bed. The lack of colour may reflect the thickness of the epidermis in the lunule and/or a paucity of capillaries in the dermis of the lunule. Nail bed The nail bed epidermis extends from the distal margin of the lunule to the hyponychium. The distal margin of the nail bed, at which point the nail plate becomes free of the nail bed, is called the onychodermal band. The surface of the nail bed is ridged and grooved longitudinally, corresponding to a similar pattern on the undersurface of the nail plate. This results in a tight interlocking of the two which prevents the invasion of microbes and the impaction of debris underneath the nail. The epidermis of the nail bed is thin and lacks a stratum granulosum. It consists of two to three layers of nucleated cells which lack keratohyalin granules, and a thin cornified layer which moves distally with the growing nail plate. It contains an occasional sweat gland distally. The dermis of the nail bed is anchored to the periosteum of the distal phalanx without any intervening subcutaneous layer. It forms a distinct compartment, which means that infections of the nail bed, or other local causes of a rise in pressure (e.g. haematoma) may cause severe pain which is only relieved by excision of part or all of the nail plate. The dermis is richly vascularized. The blood vessels are arranged longitudinally and display numerous glomus bodies, which are encapsulated arteriovenous anastomoses involved in the physiological control of peripheral blood flow in relation to temperature (see Ch. 6 and Ch. 50). The dermis is well-innervated, and contains numerous sensory nerve endings, including Merkel endings and Meissner's corpuscles. Nail bed cells differentiate towards the nail plate, and contribute to its thickness ventrally. Hyponychium The hyponychium is the area under the free nail between the onychodermal band proximally and the distal groove. It is an epidermal ridge which demarcates the junction between the finger pulp and the subungual structures. Growth of nail

Nail growth is determined by the turnover rate of the matrix cells, which varies with digit, age, environmental temperature and season, time of day, nutritional status, trauma and various diseases. Generally, its speed is related to the length of the digit, being fastest (approximately 0.1 mm per day) in the middle finger of the hand, and slowest in the little finger. Fingernails grow three to four times faster than toenails, quicker in summer than in winter, and faster in the young than in the old. A fingernail grows out in about 6 months, whereas a toenail is replaced, on average, in 18 months. Genetic keratin disorders (Irvine & McLean 1999) may lead to nail dystrophies such as pachyonychia, where the nails become grossly thickened.