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Clinics in Dermatology (2013) 31, 509–515

Nail anatomy
David de Berker, MD ⁎
Bristol Dermatology Centre, University Hospitals Bristol, BS2 8HW United Kingdom

Abstract The nail unit comprises the nail plate, the surrounding soft tissues, and their vasculature and
innervation based upon the distal phalanx. The nail plate is a laminated keratinized structure lying on the
nail matrix (15-25%), the nail bed with its distal onychodermal band (75-85%), and the hyponychium at
its free edge. The distal part of the matrix, the lunula characterized by its half-moon shape, can be
observed in some digits. The nail plate is embedded by the proximal and lateral folds. From the
proximal nail fold, the cuticle (also known as the eponychium), adheres to the superficial surface of the
proximal nail plate. The nail unit possesses a complex and abundant vascular network to ensure
adequate blood supply. Finally, both the periungual soft tissues and the nail folds are innervated. The
shapes, structure, and inter-relationships of these tissues are factors in the way nails present with disease
and how we understand and manage those diseases. In particular, an understanding of the surgical
anatomy is important for those undertaking diagnostic or curative operations on the nail. With this
knowledge, the most appropriate surgery can be planned and the patient can be provided with accurate
and clear guidance to enable informed consent.
© 2013 Published by Elsevier Inc.

Introduction bed and matrix. The laminated form is apparent when
examined histochemically1 with silver stains, by ultrasound,2
Nail anatomy entails consideration of the nail plate and by optical coherence tomography,3 and by electron micro-
periungual tissues. An understanding of these structures scopy.4 It is usually considered to be trilaminar, although
should enable a clinician to interpret nail signs with greater its physical characteristics are consistent with a bilaminar
clarity, better understand nail disease processes, and operate structure. If trilaminar, the ventral aspect possibly derived from
intelligently. The use of correct terminology also ensures that superficially adherent material generated by the nail bed. This
concepts and details of disease and treatment are accurately is given as an explanation for the increase in thickness and
documented and communicated (Figure 1). density as it grows distally.5 It also has longitudinal ridges that
correspond to complementary ridges on the nail bed (see the
section on nail bed below) to which it is bonded.
The nail plate is curved in both the longitudinal and
Nail plate (nail) transverse axes. This allows it to be embedded in nail folds at
The nail plate is a modified form of stratum corneum, its proximal and lateral margins, which provide strong
providing a laminated keratinized structure overlying the nail attachment and make the free edge a useful tool. This feature
is more marked in toes than fingers. In the great toe, the lateral
margins of the matrix and nail extend almost half way around
⁎ Corresponding author. Tel.: +0117 342 3419; fax: +0117 342 2845. the terminal phalanx. This provides strength appropriate to
E-mail address: david.deberker@UHBristol.nhs.uk (D. de Berker). the foot.

0738-081X/$ – see front matter © 2013 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.clindermatol.2013.06.006
510 D. de Berker

of time, which requires an assessment of nail-plate thickness
or mass to complement the measures of longitudinal growth.9

Lateral nail folds

The lateral nail folds provide the cushioned cutaneous
lateral margins of the nail. They are typically more prominent
in the toes than fingers, consistent with their contribution to
the firm adherence of the nail to the nail bed. When the lateral
nail fold is diminished, there is a tendency for onycholysis.
If the bulk of a lateral nail fold is excessive and incompa-
tible with the curvature and size of the nail plate, normal
embedding evolves to pathological ingrowing. This is
mainly seen on the big toe, but can be seen on other digits,
especially after trauma has altered the shape of either
structure. Although ablation of one margin of the nail is the
common solution, it can in theory also be addressed by
excision of part of the lateral nail fold. The latter is seldom
favored due to the greater morbidity.

Proximal nail fold (posterior nail fold)
The proximal nail fold is a lip of skin created around week
14 of embryogenesis as the origin of the nail creates a pocket
on the dorsum of the digit. It is adherent to the dorsal aspect
Fig. 1 Plane (a) and sagittal (b) views of nail unit. of the nail plate and conceals all or part of the nail matrix,
which is clinically manifest as the “lunula.” It combines with
the nail plate to provide a protective layer over the matrix,
The upper surface of the nail plate is relatively smooth with
which, if damaged, gives rise to a risk of permanent nail
a variable number of ridges that change with age. In childhood,
scarring. This protection extends to blocking from ultraviolet
there are often short partial oblique ridges referred to as a
radiation (UV) to supplement the natural block of the nail
herringbone or chevron pattern6 (Figure 2). With age, these
plate.10 The matrix is the sole subungual location of
disappear, and longitudinal ridges become more common.
functioning melanocytes, and their protection from UV
These ridges are sufficiently specific to allow the distinction
may diminish risk of malignancy. The proximal nail fold also
between identical twins7 and for forensic identification.8
combines with the cuticle (see below) to provide a seal
Rate of growth of the nail plate is usually undertaken as a
against irritants, solvents, and other agents that might disturb
simple measure of longitudinal elongation, using the lunula or
matrix function and hence nail growth. Trauma or infection,
proximal nail fold as a reference structure. This does not capture
with substantial inflammation, results in a wave of thinned
the more complex measure of nail-plate production per unit

Fig. 3 Lateral view of in vivo section of digit revealing Beau's
Fig. 2 Chevron pattern on dorsum of young nail. line in genesis.
Nail anatomy 511

nail in the form of a transverse groove growing out at a rate is fully obscured by the proximal nail fold. The proximal
that allows calculation of the period since the episode element reaches on average 50% of the distance from the nail
occurred. An event within a digit will limit the feature to that fold to the central crease of the distal interphalangeal joint
digit. A generalized event, such as systemic illness, may (DIPJ). Where this landmark is important for excision of the
create a groove in multiple digits. This is known as a Beau's nail unit, Reardon advises choosing a point 75% of the
line (Figure 3) and was originally described by the French distance to the DIPJ13 (Figure 4). The lunula is the pale “half
cardiologist of that name as part of global physiological moon” usually seen on the thumb but less exposed in more
disturbance following profound illness as a form of ulnar digits. The matrix creates all or most of the nail plate.
retrospective semiology.11 Chronic fluctuating inflammation This has been established by studies with injected radiolabel
of the nail fold leads to a more irregular pattern with a series to trace proliferating cells in squirrel monkey digits and later
of wavy transverse ridges and grooves in the nail. by immunohistochemistry with cell proliferation markers
Ki67 and PCNA.14 Both techniques indicate that keratinocyte
proliferation in subungual tissues is almost entirely limited to
Cuticle (eponychium) the anatomical boundaries of the matrix. Immunohistochem-
istry for keratins of hair nail differentiation paint a similar
The cuticle is a layer of epidermis extending from the picture which the hard keratin K31 again defining the classic
proximal nail fold and adhering to the dorsal aspect of the territory of the matrix with no expression within the nail
nail plate. Chronic manipulation or manicure, inflammation, bed.15 It is possible to make distinctions between the distal
or infection can result in loss of cuticle, which is often an matrix and the proximal matrix on functional grounds, given
early sign of chronic paronychia.12 Cuticle loss makes it that 81% of cell numbers in the nail plate are provided by the
more difficult for the proximal nail fold to play its protective proximal 50% of the nail matrix,14 and surgery to the distal
role and means that the first seal is broken. Regrowth of the matrix is less likely to cause scarring than more proximal
cuticle is a good indicator of resolution of an inflammatory surgery. Melanocytes and cells with common melanocyte
process. The clinical complaint of nail fold inflammation and markers are also limited to the matrix, with no extension to the
nail plate surface changes is a common sequel to manicure, nail bed. Histologically, both the nail bed and the matrix lack a
where removal of cuticle should be discouraged. granular layer. This is an important point to recognize when
assessing disease in nail biopsies, where in normal histology,
the lack of a granular layer might indicate pathology.
Nail matrix and lunula (nail root) The status of the matrix as the origin of the nail makes it
significant in instances of surgical and accidental trauma; a
The tissues beneath the nail are divided into the matrix (15- longitudinal biopsy of greater than 3 mm width is likely to
25%) and the nail bed (75-85%). Clinically, the distal element leave a permanent split in the nail.16 Once matrix damage has
of the matrix is visible in some digits as the lunula. In others, it occurred, it is difficult to repair effectively.17–19 Equally, if
surgery or trauma leads to a small island of matrix epithelium
becoming detached from the rest of the matrix, this island will
continue to produce a fragment of nail plate that will present
as a spicule arising separate from the rest of the nail and often
causing clinical nuisance at one lateral margin. This is a
particular risk when undertaking excisions or diagnostic
lateral longitudinal nail unit biopsies at the edge of the nail
unit. The lateral apex of the matrix within the big toenail is the
digit where this is most apparent. It is the least accessible
component of the matrix, and surgery should be adapted to
recognize the risk of leaving a matrix fragment in this region.
The proximal margin of the matrix appears clinically
to extend to the point of reflection of the proximal nail
fold; however, immunohistochemically, there is sometimes
a transverse zone of 1 mm of keratinocytes with K31 nail
differentiation in this region.

Nail bed (ventral matrix, sterile matrix)
Fig. 4 Surface markings of the nail fold where typical matrix
commences at the midpoint between cuticle and distal interpha- The nail bed extends from the distal margin of the lunula
langeal joint crease (A to B). Matrix excision is advised to start at to the hyponychium. Avulsion of the nail reveals a pattern of
the 75% point between cuticle and crease (CC). longitudinal epidermal ridges stretching to the lunula. On the
512 D. de Berker

The hyponychium and overhanging free nail provide a
crevice. This is a reservoir for scabies, antigens, and
microbes; it is relevant in surgery and the dissemination of
infection. After 10 minutes of scrubbing the fingers with
povidone-iodine, nail clippings cultured for bacteria, yeasts,
and molds still contain microbes.23 In 19 out of 20 patients,
Staphylococcus epidermidis was isolated; seven patients
had additional bacteria, eight had molds, and three had
yeasts. The use of a nailbrush, in addition to diligent cleaning,
does not appear to improve clearance substantially.24

Onychodermal band

The distal margin of the nail bed has a contrasting hue in
comparison with the rest of the nail bed.25 Normally, this is a
transverse band of 1-1.5 mm of a deeper pink (Caucasian) or
brown (Afro-Caribbean). Its color, or presence, may vary
with disease or compression, which influences the vascular
Fig. 5 Splinter hemorrhages in nail bed in longitudinal arrange- supply. The onychocorneal band represents the first barrier to
ment reflecting vascular pattern. penetration of materials beneath the nail plate. Disruption
of this barrier by disease or trauma represents a breach
analogous to loss of cuticle in the nail fold, with ensuing
underside of the nail plate is a complementary set of ridges, inflammation and change of behavior of the nail bed.
which has led to the description of the nail being led up the
nail bed as if on rails. The small vessels of the nail bed are
orientated in the same axis. This can be demonstrated by
using corrosion casting from cadaver digits20 and is Vascular supply
clinically manifested by splinter hemorrhages, where heme
is deposited on the undersurface of the nail plate and grows Arterial supply
out with it (Figure 5). The nail bed has a low rate of
proliferation and a complement of keratin expression that The arterial supply of fingers and toes is largely the
lacks the keratins of terminal differentiation seen in normal same. The radial and ulnar arteries supply deep and
skin, namely K1 and K10. This is reversible, and when a nail superficial palmar arcades that act as large anastomoses
is avulsed, these keratins are expressed as the nail bed between the two vessels. From these arcades extend branches
develops the more matt surface of cornified epithelium. One aligned with the phalanges. Four arteries supply each digit,
interpretation of this observation is that the nail plate is two on either side. The dorsal digital arteries are small
acting as a form or inductive influence on the underlying and arise as branches of the radial artery. They undertake
epithelium, providing the role of a cornified epithelium, so anastomoses with the superficial and deep palmar arches and
that the nail bed does not produce its own. Onycholysis the palmar digital vessels before passing distally into the
is associated with a range of changes, which include the finger. The palmar digital arteries provide the main blood
development of a granular layer, expression of keratins supply to the fingers. They receive contributions from the
of terminal differentiation, and a loss of the corrugations deep and superficial palmar arcades. Although paired, one is
on the undersurface of the nail plate. It is difficult to normally dominant. They anastomose via dorsal and palmar
disentangle cause from effect in these observations, but arches around the distal phalanx. The palmar arch is located
all three features have some relevance and possible role in in a protected position, beneath the maximal padding of the
nail-plate adherence to the nail bed. finger pulp and tucked into a recess behind the protuberant
Nail-bed dermis is sparse, with little fat, firm collagenous phalangeal boss. This is of functional value as it protects
adherence to the underlying periosteum, and no sebaceous or against occlusion of the blood supply when the fingers
follicular appendages.21 Sweat ducts can be seen at the distal exert maintained grip.
margin of the nail bed using in vivo magnification.22 The dorsal nail fold arch (superficial arcade) lies just
The hyponychium lies between the distal ridge and the distal to the distal interphalangeal joint. It supplies the nail
nail plate and represents a space as much as a surface. The fold and extensor tendon insertion. It is tortuous, with
hyponychium and onychocorneal band may be the focus or numerous branches to the nail matrix. Its transverse passage
origin of subungual hyperkeratosis in some diseases, such as across the finger can be roughly located by pushing
pityriasis rubra pilaris or pachyonychia congenita. proximally on the free edge of the nail plate. This produces
Nail anatomy 513

a faint crease about 5 mm proximal to the cuticle and is both blood flow.30 Clubbing constitutes a change in both the nail
the cul de sac of the proximal nail fold and the line of the and nail bed. It is believed that it arises secondary to
dorsal nail fold arch. neurovascular pathology. Postmortem studies suggest that it
The subungual region is supplied by distal and proximal is due to increased blood flow with vasodilatation rather than
subungual arcades, arising in turn from an anastomosis vessel hyperplasia.31
of the palmar arch and the dorsal nail fold arch. Corro-
sion casting on cadaver digits demonstrates the complex
microvasculature.20
The tortuosity of the main vessels in the finger is a
Nail fold vessels
notable feature. Vessels may turn through 270° and resemble
a coiled spring.26 Functionally, this can be interpreted as The nail fold capillary network is seen easily with a
protection against occlusion by kinking in an articulated dermatoscope with oil or gel.32 It is similar to the normal
longitudinal structure. cutaneous plexus in health, except that the capillary loops are
This complex and abundant vascular network around more horizontal and visible throughout their length. The
the nail unit provides a valuable range of arterial supplies loops are in tiers of uniform size, with peaks equidistant from
should one supply be lost through surgery or trauma. Certain the base of the cuticle. The venous arm is more dilated and
principles of surgery need to be observed to minimize tortuous than the arterial arm. Features in some disorders
the risks of local tissue ischemia. The first is always to may be sufficiently gross to be useful without magnification,
determine a path of collateral or proximal supply to any flap erythema and hemorrhages being the most obvious.
that is created. The second is to consider the universal The capillary networks in the normal nail fold of toes
reduction of supply through all vessels to the nail unit, which and fingers have been compared using video-microscopy. It
occurs with age and some pathologies. Arteriosclerosis is has revealed a greater density of capillaries in the nail fold
the most common of these, and Doppler assessment of of the toe, but with a reduced rate of flow.33 The exact
the lower limb is advisable in the elderly with risk factors pattern of an individual's nail fold vessels can be used as an
for arteriosclerosis. Where peripheral vascular disease is identifying characteristic.34
detected, surgery is best undertaken only in consultation with
a vascular surgeon; postoperative care should be meticulous
to avoid complications. Glomus bodies

The term glomus is defined as a ball, tuft, or cluster, being
Venous drainage a small conglomeration or plexus of cavernous blood vessels.
In the skin, it is an end organ apparatus, in which there is an
Venous drainage of the finger is by deep and superficial arteriovenous anastomosis bypassing the intermediary cap-
systems. The deep system corresponds to the arterial supply. illary bed. This anastomosis includes the afferent artery and
The dorsal and palmar digital veins exist superficially. These the Sucquet-Hoyer canal. The latter is surrounded by
are in a prominent branching network, particularly on the structures including cuboidal epithelioid cells and cells
dorsal aspect; however, in the microsurgical techniques possibly of smooth muscle or pericyte origin (Zimmerman
needed to restore amputations, it appears that distally, the type). These are surrounded by a rich nerve supply and the
palmar superficial veins are largest. efferent vein, which connects with the venous system outside
the glomus capsule.
The nail bed is richly supplied with glomus bodies, and
their presence in histological specimens should be inter-
Effects of altered vascular supply preted in this context, rather than assuming that their
abundance has some pathological significance. These are
Impaired arterial supply can have a considerable effect neurovascular bodies, which act as arteriovenous anastomo-
upon the finger pulp and nail unit. Samman and Strickland27 ses (AVA). AVAs are connections between the arterial and
reviewed the nail dystrophies of 41 patients with features of venous side of the circulation, with no intervening
peripheral vascular disease. In this uncontrolled study, he capillaries. The nail bed contains 93-501 glomus bodies
observed that onycholysis, Beau's lines, thin brittle nails, and per cm.3 They lie parallel to the capillary reservoirs which
yellow discoloration were all attributable to ischemia in the they bypass. They are able to contract asynchronously with
absence of other causes. It has also been suggested that their associated arterioles such that in the cold, arterioles
congenital onychodysplasia may result from digital ischemia constrict and glomus bodies dilate. They can thus serve as
in utero. 28 Immobilization might be associated with regulators of capillary circulation, acquiring the name “the
diminished local blood supply and has been noted to reduce peripheral heart of Masson” 35 . They are particularly
nail growth.29 Conversely, the increased growth associated important in the preservation of blood supply to the
with arteriovenous shunts may reflect the role of greater peripheries in cold conditions.
514 D. de Berker

after trauma in mice has also been reported,40 and both
observations are taken as supporting the concept that there is
a role for bone morphogenetic proteins (BMP).41 On a more
mechanical level, it is evident that adults with loss of all or
part of the distal phalanx develop a nail of a different shape,
usually a claw deformity, reflecting the change in forces from
the surrounding tissues. Osteoarthritis also gives rise to
changes in matrix shape, which is then reflected in the nail
plate (Figure 6).

Conclusions

A good understanding and awareness of the crossover
between anatomy, physiology, and disease processes should
enable the clinician to approach most nail pathology with an
analysis that assists patient understanding and in many
instances offers a constructive approach to therapy.

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