SPIESS MR

NAIL EXAM

 Shape
 Color
 Flexbility
 Growth rate: ~6 months from the cuticle to free
edge, 0.1mm/day
 COLORS

Pink/Red: polycythemia, SLE, carbon monoxide

poisoning, angioma, malnutrition
White: anemia, cirrhosis, DM, chemo, renal failure
Yellow: Amyloidosis, yellow nail syndrome, median/ulnar nerve
injury, thermal injury, jaundice, DM
Green/Black: solvents, trauma, chronic Pseudomonas infection
 SPOONED NAILS (KOILONYCHIA)

 Water drop test: imagine placing a drop of water on the nail. If

it would not fall of f it is spooned
 Causes:
 Iron deficiency
 DM
 Protein deficiency especially in sulfur-containing amino acids
(cysteine or methionine)
 CENTRAL NAIL RIDGE

 Causes:
 Iron deficiency, folic acid deficiency, protein deficiency
 CENTRAL NAIL CANAL/HELLER’S FIR
TREE DEFORMIT Y
 Cuticle usually normal
 Associations:
 Severe arterial disease
 Severe malnutrition
 Repetitive trauma
 NAIL BEADING

 Endocrine Conditions: DM, thyroid disease, Addison’s

 ROUGH

 Sandpaper/dull appearance
 Seen in:
 Psoriasis
 Chemical exposures
 Lichen planus
 Autoimmune diseases
 NAIL THICKENING

 Slow growth produces thickness

 Causes:
 Onychomycosis
 Chronic eczema
 PVD
 Yellow nail syndrome
 Psoriasis
 ONYCHOLYSIS

 Associated with:
 Thyrotoxicosis, trauma, contact dermatitis, chemicals, porphyria
cutanea tarda
 CLUBBING

 Angle between nail plate and fold greater than 180 degrees
 CLUBBING

 Causes:
 Cardiac/Pulmonary (80%): R to L
shunts, endocarditis, pericarditis, lung CA, bronchiectasis, lung
abscess, empyema, pulmonary fibrosis. NOT COPD
 GI (5%): IBD, celiac, neoplasms (esophagus, liver, bowel)
 Hyperthyroidism (1%)
 SPLINTER HEMORRHAGE

 A s s o c i a te d w i t h t r a u m a , I E , s c l e r o d e r m a , t r i c h i n o s i s , p i t y r i a s i s r u b r a
p i l a r i s , p s o r i a s i s , r e n a l f a i l ur e
 TERRY’S NAILS

 Proximal paleness extending at least half -way up (often

eliminating the lunula) with a dark band distally. Seen in
states of stress (liver disease, CHF, DM2, advanced age)
LINDSAY’S NAILS/HALF AND HALF NAILS

 Pale proximal (edema and anemia) in kidney and liver disease. In renal
disease there is a brown transver se distal brown transver se band at the
junction of the er ythema and free edge
 BEAU’S LINES
 Transverse depressed ridges caused by growth arrest. Seen in
severe infection, MI, hypotension/shock, hypocalcemia, post-
surgical, malnutrition, some chemotherapies
 MUEHRCKE’S LINES (LEUKONYCHIA
STRIATA)

 Due to edema to the nail plate. Usually 2 or more on one nail.

Seen in states of decreased protein synthesis or increased protein
loss, hypoalbunemia (<2.2), nephrotic syndrome and certain
chemotherapies. Don’t move and disappear when albumin
increases.
 MEES’ LINES

 Transverse white lines (usually one per nail, no depressions) that

often will disappear if pressure is applied. Heavy metal poisoning
(strong association with arsenic and thallium), chemo, severe
illness
 PITTING

 Non-specific sign for psoriasis, alopecia areata, eczema, lichen

planus
 QUITTER’S NAIL

 Distal nicotine stains with demarcation and no staining

proximally seen when a patient quits smoking or changes to a
lower tar tobacco.
 PERIUNGAL

Periungal telangiectasias: strong association with CVD:

SLE, dermatomyositis, scleroderma
Fibroma
Mucus cyst

Paronychia

Herpetic Whitlow
 ACRAL LENTIGINOUS MELANOMA

 Seen on palms, soles, mouth but when occurs within the nail
a clue is that it involves the periungal region
 HANDS

Pope’s Hand (Hand of Benediction)

What nerve is
af fected?
Claw Hand
 HANDS

Bouchard’s and Heberden’s Nodes

 HANDS

Boutonniere Deformity
Swan Neck Deformity

Ulnar Deviation
WHAT WOULD YOU EXPECT THIS PERSON
TO HAVE?
A) Turner’s Syndrome
B) Holt-Oram Syndrome
C) Down’s Syndrome
D) Edwards Syndrome
E) Fragile X
C) Down’s Syndrome
62yo F with history of proximal muscle weakness, weight loss
and dysphagia

What is causing this?

 DERMATOMYOSITIS
Periungal
telangiectasias

Gottron’s
papules
 REFERENCES

 The Stanford 25 – stanfordmedicine25.stanford.edu

 Published presentation on nail exam – Mark Williams, MD at
UVA