Hitting the Nail on the Head: Clues to Systemic Disease

Scott Sears, MD FACP Internal Medicine Associates Billings, MT

Transverse lines
A) Muehrckes Lines B) Beaus Lines C) Leukonychia punctata D) Mees Lines

Muehrckes Lines

Muehrckes Lines
What it is: an abnormality of the vascular nail bed What you see: pairs of transverse white lines that extend all the way across the nail (parallel to lunula) it goes away with nail pressure it does not grow out What its associated with: hypoalbuminemia (albumin <2) nephrotic syndrome malnutrition cirrhosis

Beaus lines

Beaus line
What it is: representation of nail growth arrest What you see: deep transverse grooves in the nail(s) can be single or multiple it does grow out the longer the insult, the wider the groove What its associated with: trauma chemotherapy systemic illness

Leukonychia Punctata

Leukonychia Punctata
What it is: minor trauma to nail cuticle or matrix What you see: non-uniform lines or spots can be single or multiple it does grow out What its associated with: minor trauma

When did this trauma occur?

Mees lines

Mees lines
What it is: nail bed ok but nail itself is microscopically fragmented What you see: milky white transverse bands seen in single or multiple nails grow distally with time width varies with the insult What its associated with: heavy metal poisoning (arsenic, thallium) leprosy malaria carbon monoxide poisoning renal and heart failure chemotherapy Hodgkins disease

Longitudinal Lines

A) Longitudinal ridging B) Splinter hemorrhages C) Melanoma D) Pigmented bands E) Habit tic deformity F) Median nail dystrophy

Longitudinal Ridging
What it is: partial dropout or malfunction of the nail matrix, which thins the nail plate What you see: longitudinal elevations that alternate with depressions or grooves along the nail What its associated with: being elderly lichen planus (can be severe) not associated with vitamin deficiencies

Melanoma vs. pigmented bands

New longitudinal band in a light-skinned person Sudden change in appearance of band (e.g., proximally wider, darker, blurred border) Single-nail involvement (especially thumb, index finger, or great toe) Pigmentation of the skin of the nail fold or proximal nail bed (Hutchinson's sign) New pigmentation in older persons (>60) Band width of more than 3 mm Family history of melanoma or dysplastic nevi Abnormal nail structure (i.e., destruction or disruption of the nail plate)

Splinter Hemorrhages
What it is: hemorrhage of the distal capillary loop What you see: longitudinal hemorrhage What its associated with: subacute bacterial endocarditis trauma (usually distal) lupus, RA, APLA pregnancy psoriasis

Median nail dystrophy, habit-tic deformity, and splitting

Damage to the matrix

Self-induced

Benign

Nails and Colors

A) Terrys nails B) Trauma C) Pseudomonas D) Yellow nail syndrome

Terrys nails
What it is: due to a decrease in vascularity and an increase in connective tissue in the nail bed What you see: white nails except for distal pink band loss of the lunula usually all the nails What its associated with: Cirrhosis (80% of cases) Diabetes CHF Hyperthryoidism Malnutrition

Pseudomonas vs. Trauma

Treatment: cut the nail as far back as possible. apply gentamicin otic solution bid alternatives include soaking in vinegar or treating with oral cipro (500mg bid x 2 weeks) may need to co-treat for fungal infection

Treatment: bore a sterile hot needle through the base of the nail make sure you are wearing ocular protection almost instant relief watch for Beaus lines to develop!

Yellow nail syndrome

What it is: delayed nail growth with associated microvascular permeability What you see: yellow, thickened nails can see loss of the lunula usually all the nails What its associated with: Lymphedema Pleural effusion Hypoalbuminemia Bronchiectasis RA

Fun pimping
How do you detect clubbing? What is the sign called? What conditions are associated with clubbing?

Clubbing

Associated conditions: Inflammatory bowel disease, lung cancer, asbestosis, chronic bronchitis, COPD, cirrhosis, congenital heart disease, endocarditis, fistulas

Nail biting

What is the single best lifestyle modification to prescribe?

Nail biting

What is the single best lifestyle modification to prescribe?

Increased physical activity!!!

Spoon nails - Koilonychia

What are the two most common conditions associated with spoon nails in adulthood?

Spoon nails - Koilonychia

What are the two most common conditions associated with spoon nails in adulthood?
1. Iron deficiency (PlummerVinson syndrome) 2. Hemochromatosis

Periungal telangectasias
What group of disorders is most commonly associated with periungal telangectasias?

Periungal telangectasias
What group of disorders is most commonly associated with periungal telangectasias?

Connective tissue diseases, especially scleroderma

References
Fawcett et al. Nail Abnormalities: Clues to Systemic Disease. Am Fam Physician 2004;69:1417-24. Dermnet.com (for images of several nail disease) Habif. Clinical Dermatology. 4th edition.