“A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT

TERTIARY CARE HOSPITAL”

A
DISSERTATION SUBMITTED TO
THE VEER NARMAD SOUTH GUJRAT UNIVERSITY,
SURAT

FOR
THE DEGREE OF
DOCTOR OF MEDICINE
(DERMATOLOGY, VENEREOLOGY AND LEPROSY)
(MAY-JUNE 2023)
“A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT
TERTIARY CARE HOSPITAL”
A
DISSERTATION SUBMITTED TO
THE VEER NARMAD SOUTH GUJRAT UNIVERSITY,
SURAT

FOR
THE DEGREE OF
DOCTOR OF MEDICINE
(DERMATOLOGY, VENEREOLOGY AND LEPROSY)
(MAY-JUNE 2023)
BY
Dr. ANSHUL
UNDER THE GUIDENCE OF
Dr. YOGESH PATEL
DEPARTMENT OF DERMATOLOGY, VENEREOLOGY
AND LEPROSY, GOVERNMENT MEDICAL COLLEGE SURAT, GUJRAT
(INDIA)
 CERTIFICATE
This is to certify that the dissertation entitled “A CROSS SECTIONAL STUDY OF NAIL
DISORDERS AT TERTIARY CARE HOSPITAL” is a bonafide record of the study carried
out by Dr. Anshul, a post-graduate student of the department of Dermatology,
Venereology and Leprology, Government Medical College, Surat; for the degree of
MD (Dermatology). The work has been carried out under direct supervision and
guidance of DR. YOGESH PATEL, Assistant Professor, Department of Dermatology,
GMC, Surat.

Date: DR. RITAMBHARA MEHTA(M.D.)

Dean,
Government Medical College,
Surat.
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 ACKNOWLEDGEMENT

It gives me immense pleasure to express my deep sense of gratitude,

indebtedness and reverence for my teacher Dr.Yogesh Patel Sir, Assistant
Professor, Department of Skin and V.D. Government Medical College and
New Civil Hospital, Surat. His special interest, in–depth knowledge of the
subject, expert guidance and critical comments has helped me immensely at
every juncture to complete this study.

I am equally thankful to Dr. Brijesh Parmar Sir, Associate Professer and

Head, Department of Skin and V.D for their valuable guidance, supervision,
and encouragement in conducting this study.

I appreciate my seniors Dr. Raj Patolia, Dr.Nilam Pala, Dr. Bhavani N S

Dr.Dharmin Mehta, Dr.Hardik Tandel, Dr.Neha Purohit for their support
and guidance.

I am also thankful to my colleagues Dr.Trunali Navadiya, Dr.Jagruti

Maheriya, Dr.Reema Kataria and my juniors Dr. Shuvendhu Dehury,
Dr.Charu Garg, Dr.Jaimin Shah, Dr.Vinas Mangukiya, Dr.Shantanu, Dr.
Kosha, Dr.Rujuta and Dr. Rishabh Vats who helped me a lot in completing
the study.

I extend my thanks to the Dean, the Superintendent and the members of the
scientific review committee and the ethical committee for allowing me to
conduct this study.
 INDEX
S. No. TOPICS PAGE NO.
1 INTRODUCTION 1
2 AIMS AND OBJECTIVES 3
3 REVIEW OF LITERATURE 5
4 MATERIALS AND METHODS 58
5 RESULTS 62
6 DISCUSSION 91
7 SUMMARY 107
8 CONCLUSION 110
9 STRENGTH AND LIMITATIONS 112
10 CASE IMAGES 114
11 BIBILOGRAPHY 119
12 ANNEXURE 127
13 KEY TO MASTERCHART 148
 List of Tables
Table No. TITLE OF THE TABLE Page No.
1 Age and sex distribution of nail disorders 63
2 Occupational status 66
3 Educational status 67
4 Socioeconomic status 68
5 No. of nail involved 69
6 Site of nail involved 69
7 Spectrum of nail disorders 70
8 Different morphological nail changes in study 72
9 Association of nail changes with cutaneous and systemic 73
conditions
10 Cutaneous conditions associated with nail changes 73
11 Nail changes along with systemic conditions 74
12 Nail changes without any association. 75
13 Types of onychomycosis 76
14 Age and sex wise distribution of onychomycosis 76
15 Onychomycosis and gender distribution 77
16 Onychomycosis according to site of involvement 78
17 Onychomycosis and socioeconomic status distribution 79
18 Occupational distribution in cases of onychomycosis 79
19 Co-relation between onychomycosis and occupational 80
status
20 Age & sex distribution of psoriasis 80
21 Pattern of nail changes in psoriasis 82
22 Site of nail involvement in psoriasis 82
23 Pattern of nail changes in paronychia 83
24 Site of nail changes in paronychia 83
25 Association of paronychia with diabetes mellitus 84
26 Pattern of nail involvement in lichen planus 84
27 Pattern of nail changes in eczema 85
28 Pattern of nail changes in alopecia areata 85
29 Pitting and its associated diseases 86
30 Association of pitting with skin diseases 86
31 Onycholysis associated with underlying dermatoses 86
32 Trachyonychia associated with underlying dermatoses 87
33 Systemic conditions with nail diseases 88
34 Distribution according to nail changes in diabetes 89
mellitus
35 Distribution of clubbing according to systemic diseases 89
 LIST OF CHARTS

CHART NO. CONTENT OF CHART PAGE NO.

1 Age and sex distribution of study 64
2 Gender distribution of patients 65
3 Occupational distribution 66
4 Educational status 67
5 Socioeconomic status of study 68
6 Age and sex distribution of onychomycosis 77
7 Site of nail involvement in onychomycosis 78
8 Age and sex distribution among psoriasis 81
 ABBREVIATIONS
DLSO- Distal & Lateral subungual onychomycosis
PSO- Proximal subungual onychomycosis
SWO- White superficial onychomycosis
TDO- Total dystrophic onychomycosis
KOH Mount- Potassium hydroxide mount
CBC- Complete blood count
HIV- Human immunodeficiency virus
TLC- Total leukocyte count
ESR- Erythrocyte sedimentation rate
COPD- Chronic obstructive pulmonary disease
CRF- Chronic renal failure
DM-Diabetes mellitus
RBS- Random blood sugar
Hb- Hemoglobin
INTRODUCTION

1
 INTRODUCTION

Nail although occupy a little area over body but it plays a significant role. Its role

in our daily routine life is quite remarkable.

Nail disorders comprises of 10% of all dermatological conditions. Nails are not

only an important aspect of the external appearance; they are also mirror of the

internal constitution like Oil-drop Sign in psoriasis and clubbing in iron deficiency

anemia. Nails not only provide aesthetic beauty to hand and feet but also aid in

providing protection, tactile sensation, and social communication.

In present era, the aesthetic aspect of the nail unit may affect occupation,

employability, self-esteem and interaction with other people.

Although, a very few studies have been undertaken with respect to nail disorders,

a study of this nature would be useful to know the spectrum of nail disorders.

2
 AIMS &

OBJECTIVES

3
 AIMS &OBJECTIVES

Present study entitled “A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT

TERTIARY CARE HOSPITAL” was carried from May 2021 to August 2022 in

department of dermatology, venereology and leprology at tertiary care hospital

after approval by Scientific Review Committee and Human Research and Ethics

Committee with following aims:

Primary objectives:

1) To identify the clinical spectrums of nail disorders.

Secondary Objectives:

1) To identify the socio-demographic distribution of nail disorder.

2) To assess the relationship between nail disorders and skin disease.

3) To assess the relationship between nail disorders and systemic diseases.

4
REVIEW OF
LITERATURE

5
 REVIEW OF LITERATURE
HISTORICAL ASPECT OF NAIL DISORDERS1
Nail always remains the most fascinating part of human body. This history part

outlines a brief overview of the history and evolution of onychology—the science

of nail.

The mention of nail, in health and diseases, is evident in the records of all ancient

civilizations. The descriptions of nail diseases in the Mesopotamian clay tablets,

various Egyptian papyri, or the ancient Indo-Iranian religio-social scripture, the Rik

Veda, attest to this fact. In the medieval period the writings of renowned authors

like Hally Abbas, Al Majusi, Albucassis, and others remind us of the medical

significance of the nails1.

The Hearst papyrus (c. BC 1550) makes many mentions of prescriptions for toe-

and fingernail diseases.

Hippocrates of Cos (BC 460–BC 370) was the first to visualize diseases in the light

of logic instead of the magico-religious point of view, which was customary until

then. His description of the nail deformity associated with lung disease

(empyema) is remembered in the clinical medicine as “Hippocratic nail” even

today. He also described various color changes of the nails as prognostic signs 2.

6
Aulus Cornelius, he described chronic paronychia. He also described how the
color changes of the nails have prognostic importance 3.
Kriton, a modestly known medical writer of the 1st century AD, described the
psoriasis of the nails4.
Modern day scientific study started with the work on the biochemical analysis of
the nails by Theophil Metecki (1837). Gustav Simon (1848), Kӧlliker (1852),
Virchow (1854), and others did pioneer work on the anatomical and cellular
aspect of the nails.
Daniel Turner (1726) described ingrown toenails and Robert Willan (1808) wrote

on psoriatic nail changes.

Famous authorities like Rayer (1835), Vidal (1855), and Hutchinson (1857)

described the eczematous changes, syphilitic affections, and melanotic whitlow,

respectively. In the present era the works of Zaias, Scher, Hashimto, Baran, and

others placed onychology on a solid foundation.

Johann-Christian Reil, the famous German physician, anatomist, and physiologist,

described a cross furrow on the nail following systemic disturbances. This was re-

described by Beau and is now known as the Beau–Reil line5.

The subject developed in rapid pace in the last 100 years with further

advancement in science and has become an important organ of modern medical

science.

7
Table mentioning about the clinical signs, describing authority, and year6.

Name of the Describing authority Year

abnormality/sign
Clubbing of nail Hippocrates of Cos --
Beau–Reil groove Johann-Christian Reil 1796
Honoré Simon Beau
Hutchinson sign Jonathan Hutchinson 1857
Koilonychia Radcliffe Crocker 1893
Nail–patella syndrome EM Little 1897
Mees lines RA Mees 1919
Median canaliform J Heller 1928
dystrophy
Lovibond angle JL Lovibond 1938
Curth’s modified profile HO Curth 1953
sign
Muehrcke band RC Muehrcke 1956
Pterigium inversum ME Caputo, G Prandi 1973

unguis

Twenty-nail dystrophy DE Hazelrigg, C Duncan, 1977

M Jarratt

Congenital malalignment of big toenail described by “PD Samman” in 1978.

Whereas the Congenital hypertrophy of the lateral fold of the hallux described by

Martinet in 1984.

8
The unfolding of the causes of different nail disorders led to newer and better

strategies of managing nail diseases and a range of newer modalities of

management like surgery, cryotherapy, laser, and prosthetics have opened

several new avenues in onychology today.

EMBRYOLOGY OF NAIL 7

Embryologically nail develops from the ectoderm. It is an important part of our

integumentary system. The finger nail development commences at 8–9 weeks
of gestation. Initially there is development of an uninterrupted groove by

invagination of the primitive epidermis, termed as the nail field.

A group of cells from the proximal area of the nail fold then grows on the digit

which halts about 1 mm from phalanx, this gives rise to the matrix primordium.

This site will further contribute to the development of epithelium of the proximal

nail fold, the distal and intermediate matrix epithelium.

At 13 weeks gestation: the proximal nail fold is formed and the signs of growth

of nail plate is noticed from the lunula. At this stage, the stratum corneum and

stratum granulosum start to appear, from the nail field epithelium commencing

distally.

9
At 18 weeks: The granular layer recedes and disappears and at 20 weeks

gestation, the process of maturation and cellular differentiation in the matrix

occurs which is similar to that of adults.

At 32 weeks of gestation: nearly all the parts of the nail can be seen. In the toe

nail the developmental process starts about 4 weeks later than the finger nail.

Nail plate in toenails reaches the tip later at 36 weeks only and absent nail plates.

Diagramatic view of intrauterine development of Nail apparatus.

10
Diagramatic view showing gross anatomy & saggital section of Nail.

11
 GROSS ANATOMY

The nail unit consist of following units:

• Nail matrix

• Nail plate

• Nail bed

• Nail fold

• Cuticle

• Lunula

NAIL MATRIX:

Matrix is a specialized epithelial structure that lies above the mid portion of the
distal phalanx. The width and thickness of the nail plate is determined by the size,
length, and thickness of the matrix. It is wedge- shaped on longitudinal sections
and can be subdivided into

• Dorsal (the ventral aspect of the proximal nail fold)

• Intermediate (germinal matrix)

• Ventral (nail bed) sections

Cells of the proximal half of the matrix produce nearly 80% of the nail plate,
whereas <1% of nail plate is contributed by nail bed.8 The loss of matrix due to

12
surgery or trauma may result in the decreased width of nail plate or split nail
plate. Hence, biopsy with a width more than 3 mm is not recommended.

Histology: The matrix, at the nail base is composed of germinative epithelium

without a granular layer. The rete ridges of the matrix run obliquely in a proximal
direction, with their tips dorsally oriented and this leads to a nail plate growth
which is at an angle out of the digit. The epithelium of the matrix becomes
keratinized through onychokeratinization, producing hard keratin which forms the
nail. 9

NAIL MATRIX MELANOCYTES:

Nail matrix contains melanocytes in the lowest two cell layer. Under normal
circumstance the matrix is unable to produce melanin. On an average the
melanocytes in the nail matrix are about 217/sq mm and more numerous in distal
part of matrix. The nail bed devoid of melanocytes 9,10. Langerhans cells are also
demonstrated in nail
matrix.

LUNULA:

Lunula represents the distal most part of matrix, which is not completely covered
by the proximal nail fold but is visible through the nail plate as a white half-moon-
shaped area, called the lunula. The white color of the lunula results from two
main anatomic factors.

Light diffraction caused due to nuclear fragments in the keratogenous zone of the
distal matrix.

13
Due to less firm attachment of lunula to the nail bed and due to the thickness of
the nail matrix epithelium11.

NAIL PLATE:

The nail plate is composed of hard keratin in a translucent horny plate and it
progressively thickens from its emergence to its distal margin.

The thickness of nail increases with age and depends on the nail matrix and nail
bed. Thinning of the nails is a sign of nail matrix disorders. In males the mean
thickness of finger nails is 0.6 mm and toe nail is 1.65+0.43 mm. Mean thickness
of finger nail in female is 0.5 mm and toe nail is 1.38 +0.2 mm 2.

The proximal nail matrix contributes to nearly 80 % of nail plate. The nail bed
contributes to the ventral part which makes up to nearly 1/5th of nail plate.
Lunula of the nail plate being thinner, consists of only the dorsal and intermediate
portions.

Histology: The nail plate is made up of flattened squamous cells which are closely
oppose due to the interlocking plasma membranes 11. Tightly packed cornified
cells onychocytes are in a lamellar pattern of arrangement that staining pale pink
with hematoxylin and eosin.

14
NAIL BED:

The soft tissue over which the nail rests is called nail bed. Its extent ranges from
the distal margin of the lunula to the onychodermal band. It is comprised of
epithelium, an underlying abundant vascular dermis which is in continuation with
the periosteum of the distal phalanx. It contributes to the formation of the nail
plate.

Histology: The nail bed comprises of a thin epidermis which is only two to three
cell thickness and a dermal layer, but devoid of subcutaneous fat. The rete ridges
and dermal papilla are long and narrow in the nail bed. The dermal layer of the
nail bed contains rich blood vessels to the supply nail unit. 12,13 The transitional
zone from living keratinocyte to dead ventral nail plate cell is abrupt. There are no
follicular or sebaceous apparatus in the nail bed except at the distal end.

NAIL FOLDS:

The proximal nail fold is a continuation of the skin of each digit, forming the
dorsal surface that folds underneath itself forming the ventral surface and rests
above the nail matrix. The dorsal proximal nail fold is devoid of hair follicles,
sebaceous glands, and dermatoglyphic markings. The proximal nail keratinizes by
formation of cuticle (Eponychium), which is attached to the upper surface of the
nail plate14.

The lateral nail folds are soft tissues that partially cover the nail plates on radial
and ulnar sides and contribute to the firm adherence of the nail plate to the nail
bed. They are typically more prominent in the toes than fingers. Loss of volume of
lateral nail folds is associated with a tendency for onycholysis.

15
HYPONYCHIUM:

The hyponychium is an epithelial area underlying the free edge of the nail plate.
The hyponychium is the first site of keratinization in the nail unit and of all
epidermis in the embryo. Hyponychium is the initial site of invasion by
dermatophytes in the most common type of onychomycosis, distal subungual
onychomycosis.

CUTICLE:

It is semicircular layer of invisible dead skin cells that rides out on and cover the
back of visible nail plate.

BLOOD SUPPLY OF NAIL:

Nail bed and nail matrix receive their arterial blood supply from paired
digital arteries; one of them is a large palmar artery, supplied from the larger
superficial and deep palmar arcades, and the other is a small dorsal digital artery
on either side.

These arteries form three arcades: distal subungual arcade, proximal

subungual artery and superficial arcade. The main supply passes into

the pulp space of the distal phalanx before reaching the dorsum of the digit. The
main arterial arches are formed from anastomoses of the branches of the digital
arteries supplying the nail bed and matrix. Further, they can be categorized into
three patterns:

16
(1) vessels that are longitudinal with helical twisting within the matrix.

(2) vessels which runs in longitudinal axis in the nail bed and in the distal proximal
nail fold without the tortuosity.

(3) vessels that follow the pattern of the dermatoglyphic in the digit pulp 15,16.

Diagramatic presentation of blood supply of Nail .

17
NERVE SUPPLY OF NAIL:

Dorsal branches of the paired digital nerves give rise to the cutaneous sensory
nerves that run parallel to the digital vessels. Corresponding palmar and plantar
digital nerves innervate the pulp of the distal digit up to the margin with the
hyponychium. Fingertips play an important role in the sensory perception with
abundant nerve endings that transmit pain (type I fibers), touch (Meissner and
Pacinian bodies), and temperature 16,17.

NAIL GROWTH:

The rate of nail growth depends on various physiological, environmental, and

pathological conditions. The rate of nail growth peaks between the ages of 10 and
14 and then begins a steady decline with age after the second decade. Fingernails
have a growth rate of approximately 0.1 mm per day (mean growth rate
3.5 mm/month) in adults. Toenails grow at one-third of this rate (0.03 mm/day).
The regeneration time for a fingernail is around 100– 180 days (6 months)
whereas for a toenail it is 12–18 months 15,17,18.

LYMPHATIC SUPPLY:

There are numerous lymphatic vessels in nail bed near the free edge of
nail plate and the superficial network joins the deep trunk by anastomotic rami 11.

18
BIOCHEMICAL:

The nail plate, consists mainly of low sulfur filamentous proteins embedded in an
amorphous matrix composed of high sulfur protein rich in cysteine

• Nail keratins contains 80% to 90% of hard hair type keratins and 10% to 20%
soft type keratins.

• The epithelial keratin expressed in the nail are K5/K14, K6/K16 and K19 is
present only in nail bed epithelium13.

• The total fat content of nail is 0.1—1.0.%.

• The main lipid in the nail is cholesterol

• Water content is 7% - 12%

• Calcium is 0.1% and calcium level in elderly is 1% 19.

• Trace elements like copper, manganese, iron, copper and phosphorus are
present only in small amount.

19
Physiological nail Changes in correlation with age

NAIL CHANGES IN CHILDHOOD NAIL CHANGES IN OLD AGE

• Thinner nail plates with temporary
koilonychias
• Single beau lines
• Punctuate leukonychia
• Lamellar splitting of free end
• Soft and brittle nails with splitting
• Nails appear pale lusture less and dull
• Koilonychias
• Longitudinal ridging

20
 NAIL UNIT SIGNS

Name Description Clinical Pictures

ALTERATION IN NAIL PLATE SIZE:

Micronychia Abnormal small nails

Brachyonychia Short nail in which width

of nail plate &nail bed is

greater then length.

Onychoatrophy Faulty underdevelopment of

nail in which there is reduction

in size and thickness of the nail unit

21
Onychodystrophy Nails become thickened, or

exihibit a partially destroyed

nail plate.

Macronychia Abnormally large nail

Anonychia Complete absence of nail

in one or more fingers or toes

ALTERATION IN NAIL PLATE THICKNESS AND CURVETURE

Pachyonychia Thickened nail with increased

transverse curvature.

22
Onychochauxis Thickened nail with yellowish

discoloration without any change

in the curvature of the nail plate

Onychogryphosis Nail plate thickening with gross

hyperkeratosis and increased

curvature of the nail plate.

Koilonychia/Spoon nails Abnormally thinned and concave

nails with raised edges giving

an appearance of spoon.

23
Clubbing Swelling of the distal digit with

enlarged and excessively curved

nail plate resulting in loss of

normal angle between proximal

nail fold and the nail plate.

Pincer nail (Omega nails) Excessive transverse curvature

of nail plate, resulting in

compression of the nail bed

and underlying dermis.

onychoclavus Hyperkeratotic tissue in the nail

area, mostly under the distal nail

margins, due to a bony deformity

or repeated minor trauma.

24
ALTERATIONS IN NAIL PLATE COLOR

Chromonychia Change in normal

“pink translucent appearance”

of nail plate.

Leukonychia Nail plate appears white.

The whole or the part of nail

plate may develop leukonychia.

Mee’s line A single or multiple, transverse,

narrow (1–2 mm thick) whitish

line running along the width of

nail and parallel to lunula.

Melanonychia Nail plate develops brown or

black discoloration.

25
ALTERATION IN NAIL PLATE SURFACE

Longitudinal ridge Small linear projection

extending from proximal

nail fold to free distal end

of nail plate.

Nail beads Small linear projection may

be interrupted at regular

intervals, giving rise to

beaded appearance.

Longitudinal groove Shallow furrow on the

surface of the nail plate.

Median nail dystrophy Longitudinal defect of thumb

and great toenails in the midline,

starts from cuticle.

26
Trachyonychia Brittle nail with excessive

longitudinal ridging, imparting

a rough surface

Pitting Pits are superficial depressions

within the nail plate.

Beau’s lines Transverse groove(s) running

from side to side on nail and

reflecting temporary reduction

in matrix activity.

Onychomadesis Spontaneous separation of nail

plate from the matrix area

Onychoschizia • Splitting of the distal nail plate

into layers at the free edge

27
ALTERATIONS IN LUNULA

Red lunula • The lunula, which is usually

of a ground-glass appearance,

may become reddened.

Blue lunula • Blue color of lunula, seen

in Wilson disease, treatment with

Hydroxyurea etc.

NAIL FOLD SIGNS:

Paronychia Inflammation of the nail folds, with

erythema, swelling, pain, and

impaired activity.

Pterygium A linear forward growth of the

proximal nail fold, which fuses

with the underlying matrix

and subsequently with the nail

28
 bed, dividing the nail plate in two.

Hutchinson’s sign Periungual extension of brown-

black pigmentation from

longitudinal melanonychia

onto the proximal and lateral

nail folds.

Ingrown nails Periungual inflammation and pain

resulting from penetration of part

of the nail plate into the soft tissues.

NAIL BED SIGN

Muehrcke’s lines Double white transverse lines

Seen in hypoalbuminemia

29
Terry’s nails Apparent leukonychia characterized

by ground glass opacification of nearly

the entire nail, obliteration of the lunula

Half-and-half nail Nail consists of two segments separated

more or less transversely by a well-

defined line.

Onycholysis Detachment of the nail plate from its bed

at its distal end or its lateral attachments

Plummer’s nail Onycholysis affecting the ring and

little fingers, seen in patients with

thyrotoxicosis etc.

30
Photo-onycholysis it is a triad of photosensitization,
onycholysis, & dyschromia

Subungual hyperkeratosis Excessive proliferation of

nail bed keratinocytes

characterized by accumulation

of scales under the nail plate

Splinter hemorrhages Appear as one or more red-

brown striae in the distal

part of the nail and correspond

to hemorrhages of capillaries

of the nail bed

31
Salmon patch Yellow-red hue of the nail bed

due to glycoprotein of the serum

associated with inflammation.

Subungual hematoma Deep-red to black discoloration

of the nail due to extravasation

of blood between nail plate and

nail bed following trauma.

Nails in dermatological Diseases.

ECZEMA:

Eczema is characterized by itching, redness, edema, papulovesicles in the acute

stage; edema and scaling in the subacute stage; and dry lichenified skin in the
chronic stage. During the course of disease there is involvement of nails also.

Eczema of proximal and lateral nail folds results in erythema, edema, and loss of
cuticle. Secondary bacterial infection can result in acute paronychia. Eczematous
changes in nail matrix result in rough, thick, discolored nail plate with surface
pitting. Recurrent and intermittent inflammation may result in Beau’s lines.

32
Nail changes in various eczemas:

Allergic contact dermatitis • Splinter hemorrhages, subungual hyperkeratosis,

paronychia, onycholysis20.
• Less common changes: erythema, scaling, painful
fissuring of nail folds

Irritant contact dermatitis • Paronychia, onycholysis, subungual

Atopic dermatitis and
atopic palmar eczema
hyperkeratosis21, onychorrhexis.
• Features more marked in dominant hand, and in
first three fingers21.
• Koilonychia: may be seen with use of organic
solvents and motor oils21.
Polished shiny nails21
• Nail pits, transverse grooves, trachyonychia, nail
dystrophy18,21
• Increased prevalence of Staphylococcus beneath
nails20,21

Exfoliative dermatitis • Polished shiny nails21.

ALOPECIA AREATA:

Alopecia areata (AA) is a common condition characterized by a patchy loss of hair

without atrophy. It may affect any hairy area of the body and is usually reversible.

Pitting is the most common nail abnormality followed by trachyonychia and

onychorrhexis . Pits presents as fine, grid-like stippling with regular vertical and
horizontal rows. Twenty nail dystrophy in severe cases is also reported.

33
Histologically spongiotic dermatitis of the matrix (and nail bed) with exudation of
serum is seen which becomes incorporated into the nail plate. The inflammation
and incorporation of serum and inflammatory cells cause a wavy arrangement of
the onychocytes and their keratin fibers resulting in roughened appearance of
nails. The severity of nail changes appears to be proportional to the degree of hair
loss.

Common nail changes • Pits, trachyonychia, onychorrhexis, twenty-nail

dystrophy.

Less common changes • Beau’s lines, nail plate thickening/ thinning,

transverse and longitudinal fissuring of nail plate,

leukonychia (may be punctate, transverse, or

diffuse)22, spotting of lunula, onycholysis,

onychomadesis23.

PITYRIASIS RUBRA PILARIS:

Pityriasis rubra pilaris (PRP) is a rare chronic papulosquamous disorder of

unknown etiology characterized by reddish orange scaly plaques, palmoplantar
keratoderma, and keratotic follicular papules.

The nail involvement in different types of Pityriasis Rubra Pilaris (PRP) is common
and is more pronounced when there are skin lesions on dorsal of the fingers23.

34
Histologically, the nail bed epithelium reveals parakeratotic areas, acanthosis, and
focal basal liquefaction. Keratohyalin granules may be seen. In the dermis, there is
a mononuclear inflammatory infiltrate 22.

Common nail changes • Thick nails, subungual hyperkeratosis, splinter

hemorrhages, longitudinal ridging, and a distal

yellow-brown discoloration22.

Uncommon findings • Irregular pitting, Beau’s lines, loss of cuticles, and

erythema around proximal nail folds 24.

PSORIASIS:

Psoriasis is characterized by hyperproliferation and abnormal differentiation of

epidermal keratinocytes, lymphocyte infiltration consisting mostly of T-
lymphocytes, and various endothelial vascular changes in the dermis, such as
angiogenesis, dilatation, and high endothelial venule formation.

Fingernails are more commonly involved in psoriasis then toenails. Classically, nail
psoriasis presents as pitting, onycholysis, subungual hyperkeratosis, nail bed
discoloration, and onychodystrophy. Other nail manifestations include the
diagnostic salmon patch/oil drop, leukonychia, splinter hemorrhages, red spots in
the lunula, and crumbling of nail plate25,26. Several studies have reported pitting to
be the most common sign. This is closely followed by onycholysis.

35
Site of Nail matrix Nail bed Nail fold
involvement
Clinical features Pitting Onycholysis Paronychia
Beau’s lines Oil spot/salmon Acropustulosis
patch
Leukonychia Subungual Psoriatic plaque
hyperkeratosis
Red spot in lunula Splinter Glomerular
hemorrhage dilation of
capillaries

Onychomadesis Discoloration Nail fold

capillaroscopic
abnormalities

36
LICHEN PLANUS:
Lichen planus (LP) is an inflammatory, papulosquamous disorder affecting either

or all of the skin, mucous membranes, hair, and nail. Nail LP can present with

very diverse morphological patterns and is characterized by thinning, longitudinal

ridging, and distal splitting of the nail plate 27.

Characteristic nail lesions of LP include dorsal pterygium and trachyonychia. An

early change in the existing nail plate is the “pup tent” appearance of the distal
normal nail plate where the nail plate separates from the nail bed and is lifted up,
with the lateral edges sloping when the nail is seen end-on.

Nail component involvement resultant changes

Nail matrix involvement
Nail bed involvement
Nail fold changes
• Longitudinal ridging
• Trachyonychia
• Pterygium
• Irregular nail pitting
• Onychorrhexis
• Crumbling
• Fragmentation of the nail plate
• Violaceous lines or papules visible through nail
plate
• Subungual hyperkeratosis
• Onycholysis
• Lateral pterygium (hypertrophic lesions
involving proximal and lateral nail folds)

37
Darier’s Disease:

The nail changes in Darier’s disease are not only common but also diagnostic. The
“candy-cane” appearance of the nails, especially when it ends in a V-shaped notch
at the distal nail edge, is considered pathognomonic 28,29.

Nail matrix findings • Thinned nail plate, longitudinal ridges,

onychorrhexis, increased fragility of nail plate,
true leukonychia.
Nail bed findings • Subungual hyperkeratosis, distal cuneiform
keratosis, and sometimes splinter hemorrhages.
Nail fold • Keratotic papules on proximal nail fold may
present as paronychia
Others • Secondary infection with dermatophytes,
Candida and Pseudomonas spp.

STEVENS JOHNSONS SYNDROME/TOXIC EPIDERMAL NECROSIS:

As in skin, inflammation and bulla formation can occur in any portion of the nail
unit. The inflammatory reaction can cause damage to the nail fold, matrix, nail
bed.30

Nail changes in SJS-TEN31

Common • Paronychia, onychomadesis

Uncommon • Nail degloving syndrome
Long term sequale • Nail dystrophy and permanent anonychia
• Scarring and pterygium
• Onychodystrophy

38
PEMPHIGUS VULGARIS:
Nail changes in pemphigus have been found more frequently in patients with
larger number of bullae and longer disease duration, thus correlating with disease
severity32.

Nail involvement is due to bullous lesions developing in the nail bed, nail matrix,
or nail fold as part of the disease process. Nail disease can be part of the initial
presentation along with mucosal and cutaneous lesions, can precede a flare of the
pre-existing disease, or can be the only sign of the disease 33.

Nail changes in pemphigus vulgaris34:

common • Acute paronychia

• Onychomadesis
• Onycholysis and subungual hyperkeratosis
others • Onychodystrophy
• Subungual, intraungual, and splinter hemorrhages
• Beau’s lines, pitting, onychoschizia, and longitudinal
ridging, trachyonychia
• Onycholysis
• Nail plate discoloration
• Vegetating and verrucous lesions on the nail fold

39
BULLOUS PEMPHIGOID:

All four regions of the nail, namely the proximal nail fold, nail matrix, nail bed, and
hyponychium, express the antigens found in the non-appendageal basement
membrane, including BP1Ag and BP2Ag. It is therefore not surprising that the
inflammatory process of BP can also involve the nail resulting in nail changes 35.

Nail changes in bullous pemphigoid 36

Nail folds • Paronychia

Matrix • Longitudinal splitting of the nail, Beau’s
lines, and onychomadesis
Severe inflammation of nail • Nail unit scarring with atrophy or even
fold and matrix permanent loss of the nails, anonychia, and
pterygium
Nail bed • Onycholysis37

40
DISCOID LUPUS ERYTHEMATOSUS:

Nail findings of discoid lupus erythematosus 38:

Site of involvement Nail finding

Nail matrix Scarring, pterygium
Nail bed Diffuse or punctuate reddish-blue discoloration
Nail fold • Focal lesions of DLE occurring over the nail fold
produce nail plate dystrophy with onychorrhexis
• Distally, the nail plates crumble and become fragile,
irregular, and split.

SYSTEMIC LUPUS ERYTHEMATOSUS:

Nail findings are indicative of active disease and are associated with significantly
higher incidence of Raynaud’s phenomenon and oral ulceration 39.

Site affected Nail findings

Proximal nail fold • Most important site to get affected in SLE.
• Nail fold erythema, chronic paronychia, nail fold
hyperkeratosis, and ragged cuticles.
Nail bed • Onycholysis
• Oil spots and subungual nail bed
hyperkeratosis39
Nail matrix • Punctate or transverse leukonychia, nail pitting or
ridging, Beau’s lines, and onychomadesis 39
• In transverse leukonychia, the width of the
leukonychia correlates with the duration and clinical
activity of the SLE.

41
SYSTEMIC SCLEROSIS:

Digital ischemia associated with Raynaud’s phenomenon and inflammation of the

nail matrix may be observed in scleroderma and are responsible for variety of nail
changes.

Site affected Nail findings

Blood vessels • Reversible pallor and cyanosis, hyperemic distal nail
(Ischemic/ vascular bed
changes) • Prolonged ischemia and subsequent fibrosis results in
pseudo-clubbing or “beaking” of the nails, fingertip scars,
and pterygium inversus unguium40,41
• Painful, keratotic ulcers that may progress to digital
necrosis and gangrene40,41
• Splinter hemorrhages
• Ragged cuticle, cuticular hemorrhage
• Red lunula
Nail matrix Nail plate pitting and beading
involvement • Trachyonychia and brachyonychia
• Thickened nails
• Macrolunula42

42
Nail changes in systemic conditions:
Nail changes associated with specific conditions 43.
Nail changes Example Asso. Systemic condition.

• True leukonychia Mees’ lines Arsenic poisoning

• Apparent
leukonychia Muehrcke’s lines Hypoalbuminemia

Half-and-half nails Renal diseases

Terry’s nail Hepatic cirrhosis

• Clubbing
Cardiopulmonary
diseases

CLUBBING:
Clubbing is characterized by increased nail plate curvature longitudinally and
transversely with soft tissue hypertrophy of the digital pulp, usually involving all
20 digits. There are three forms of geometric assessment that can be performed.

The Lovibond's angle is found at the junction between the nail plate and proximal
nail fold. and is normally less than 1600. This is altered to over 1800 in clubbing.

Curth's angle at the distal interphalangeal joint is normal about 1800. This
diminished to less than 1600 in clubbing. Schamroth's window is seen when the
43
dorsal aspect of two fingers from opposite hands are opposed revealing a window
of light, bordered laterally b the Lovibond angles. As this angle is obliterated in
clubbing, the window close44,45

Causes of clubbing
● Cyanotic congenital heart diseases
● Bronchiectasis
● Cystic fibrosis
● Hepatic cirrhosis
● Primary and metastatic lung cancer
● Lung abscess
● Mesothelioma
● Inflammatory bowel disease
● Arteriovenous malformation
● Idiopathic

KOILONYCHIA:

It is the presence of reverse curvature in the transverse and longitudinal axes that
gives a concave dorsal aspect to the nail46. These changes result in spooning of
the nails capable of retaining a drop of water. The petaloid nail is an early stage of
koilonychia and is characterized by flattening of nails46.

44
 Causes of koilonychia
● Idiopathic
● Iron deficiency anemia
● Hemochromatosis
● Coronary disease
● Thyroid disorders
● Upper gastrointestinal malignancy
● Traumatic injury
● Nail exposure to chemicals and acitretin
● Occupational
● Raynaud’s disease
● Systemic lupus erythematosus
● Nail–patella syndrome
● Old age
● Digital ischemia
● Psoriasis

PINCER NAILS:

Pincer nail (also known as omega nails) is a toenail disorder that is characterized
by transverse over-curvature along the longitudinal axis, in which the lateral
edges of the nail slowly approach each other reaching to its greatest proportion
toward the tip. Pincer nail has been reported in systemic lupus erythematosus
and amyotrophic lateral sclerosis46,47.

ONYCHOLYSIS:

Onycholysis refers to the distal separation of the nail plate from the nail bed. Nails

with onycholysis are usually smooth, firm, and without nail bed inflammation.

45
 Systemic causes of onycholysis48,49,50
● Anemia
● Bronchiectasis
● Lung cancer
● Cutaneous T-cell lymphoma
● Diabetes mellitus
● Thyroid disorders
● Porphyria
● Lupus erythematosus
● Psoriatic arthritis
● Sezary syndrome
● Drugs (psoralens and tetracyclines)
● Vitamin C deficiency

BEAU’S LINES:

These run along the transverse axis of the nail and may be of full or partial
thickness. Beau’s lines occur at the same spot of the nail plate in most or all the
nails and may be caused by any disease severe enough to disrupt normal nail
growth. It is the most common and least specific nail change in a systemic
disease. They appear first at the cuticle and move distally with nail growth.

Beau’s lines in systemic diseases

● Severe acute illness such as
● Fever
● Heart attack
● Exposure to extreme cold
● Psychological stress
● Poor nutritional status
● The presence of Beau’s lines on all 20 nails is seen in
● Mumps

46
 ● Pneumonia
● Coronary thrombosis
● Kawasaki disease
● Syphilis
● Hypoparathyroidism
● Trauma involving proximal nail fold

ONYCHOSCHIZIA:

Horizontal splitting of nail toward its distal portion is also called lamellar splitting
of nail. It is also called lamellar dystrophy. This can result in discoloration of the
nail due to sequestration of debris between the layers 49,50.

Conditions associated with onychoschizia

● Trauma – most common cause
● X-linked chondrodysplasia punctata
● Polycythemia rubra vera
● Systemic retinoid therapy

SPLINTER HEMORRHAGE:

Splinter hemorrhages in nails are tiny bleeding points in the nail bed and
hyponychium of the nail unit. They are formed by the extravasation of blood from
the longitudinally oriented vessels of the nail bed .

47
 Systemic causes of splinter hemorrhage48,49,50
● Infective endocarditis
● Rheumatic heart disease
● Valvular replacement
● Connective tissue diseases like systemic lupus erythematosus and
scleroderma
● Antiphospholipid syndrome
● Intravenous drug abusers
● Congenital heart diseases
● Drugs – aspirin

MELANONYCHIA:

Systemic causes of melanonychia48,49,50

● Hemochromatosis
● Malnutrition
● Thyroid disease
● Smoking
● HIV infection
● Addison’s disease
● Drugs – Antimalarials, Minocycline, Phenytoin, Psoralens, sulfonamides,
zidovudine

RED LUNULA:

Red lunula result from increased arteriolar blood flow, a vasodilatory capacitance
phenomenon, or changes in the optical properties of the overlying nail so that
normal blood vessels become more apparent.

48
 Systemic conditions associated with red lunula 49,51
● Chronic obstructive pulmonary disease
● Rheumatoid arthritis
● Systemic lupus erythematosus
● Cardiac failure
● Cirrhosis of liver
● Carbon monoxide poisoning
● Twenty-nail dystrophy
● Reticulosarcoma

Nail changes associated with endocrine disorders52:

Disorders Nail Abnormality

Acromegaly Thick nails; short, wide, flat nails; onychoschizia,
absent lunula.
Addison’s disease Longitudinal pigmented bands.
Hypoparathyroidism Opaque, brittle nails; longitudinal lines and transverse
ridges.
Polyglandular Candidial paronychia; Beau’s lines
autoimmune
Hyperparathyroidism Chronic paronychia; pseudo-clubbing
Hyperthyroidism Plummer’s nails clubbing, yellow nail syndrome,
splinter hemorrhages; increased nail growth; soft,
shiny nails; onycholysis
Hypothyroidism Hapalonychia; slow growth; longitudinal sulci;
transverse striations; brittle nails; onycholysis.

49
Nail changes in diabetes mellitus53:

Infection Vascular lesions Neuropathy Miscellaneous

Acute paronychia Beau’s Lines Trauma Rosenau’s

depressions

Chronic paronychia Onychauxis Onychauxis Onychogryphosis

Onychomycosis Pterygium unguis Onychocryptosis Pincer nail

deformity

Onycholysis Pterygium Reflex sympathetic Leukonychia

inversum unguis dystrophy

INFECTIONS OF NAIL FOLDS AND NAIL UNITS.

T. Unguium &Onychomycosis:

Tinea unguium is clinically defined as a dermatophytic infection of the nail plate.

The term onychomycosis includes all infections of the nail caused by any fungus
including non-dermatophytes and yeasts.

Epidemiology: Onychomycosis is a common infection and accounts for 20% of all

nail diseases54. Most of the fungal nail infections are exclusively seen in adults.
The faster nail growth in children protects them. Dermatophyte nail infections are
more common in men than women. Other contributory factors for tinea unguium

50
include poor peripheral circulation, trauma to the nails and old age when the
linear nail growth is slow55,56.

Pathogenesis: Invasion of the nail plate usually occurs either from the lateral nail
fold or from the free edge. Subungual hyperkeratosis frequently occurs.

Etiology: Onychomycosis can be caused by dermatophytes (most commonly,

Trichophyton rubrum, T. mentagrophytes var. interdigitale and Epidermophyton
floccosum), yeasts (Candida albicans, Hendersonula toruloidea) and non-
dermatophytic molds (Scopulariopsis brevicaulis, Aspergillus, Fusarium,
Cephalospor ium species). Microsporum nail infections are extremely rare56-60.

Dermatophytes: According to multiple surveys, dermatophytes are the most

frequent of the pathogens that cause Onychomycosis 54,57,60 most dermatophyte
infections of the nail are associated with tinea pedis, which is the most common
fungal infection in developed countries. Although tinea pedis is regarded clinically
as a relatively trivial infection, if left untreated, it will progress to nail disease in
approximately one third of cases . Throughout the world, the most common cause
of onychomycosis is Trichophyton rubrum.

Candida species: Candidal infection of the nails almost always involves the
fingernails, although in some Muslim countries, the religious practice of washing
the feet five times daily may be a possible route of candidal infection of the
toenails. The three organisms responsible for most candidal infections include
Candida albicans, C. parapsilosis, and C. guilliermondii. However, there is some
question as to whether Candida is truly able to break down nail material or that it
actively invades the proximal nail bed.

51
Classification of onychomycosis: Three groups of organisms are associated with
onychomycosis: dermatophytes, Candida species, and nondermatophytic molds.
The most likely causative agent can be identified on the basis of which of the four
specific clinical types of onychomycosis present.

Distal and Lateral Subungual Onychomycosis (DLSO): The most common pattern
of infection and usually presents streak or a patch of discoloration, white or
yellow at the free edge of the nail plate often near the Lateral nail fold.
Subsequently the infection moves proximally in the nail bed & invades the ventral
surface of the nail plate. The nail plate becomes obviously thickness & may crack
as it is lifted up by the accumulation of soft subungual hyperkraterosis. A late
phase of invasion may lead to massive destruction of the nail plate (total
dystrophic onychomycosis; TDO).

Superficial White Onychomycosis (SWO): This is a less common presentation and

can produce a distinct from of nail invasion in which the dorsal surface of the nail
plate is eroded in well-circumscribed powdery white patches, often away from
the free edge. It is distinguishable from other causes of leukonychia by the
powdery nature of the white material, which can easily be scraped away.
Although more common with T. mentagrophytes var. interdigtalle, it can
occasionally be seen in T.rubrum infection and also occurs with certain non-
dermatophytes. Toenails are usually affected 60.

Proximal Subungual Onychomycosis (PSO): This is a pattern that was very

uncommon, but recently has become particularly associated with AIDS cases.
Rapid invasion of the nail plate from the posterior nail fold may develop to

52
produce a white nail with only marginal increase in thichkness55. The most
common cause is currently T.rubrum.

Endonyx Onychomycosis (EO): This is seen with infection caused by

dermatophytes that cause endothrix scalp infections, notably T.soudanense
from the top surface, but penetrates deeply into the nail plate 61.

Total dystrophic onychomycosis (TDO): It represents the most advanced form

where infection progresses to total destruction of the entire nail including the nail
plate, nail bed, and matrix. The nail crumbles leaving behind a thickened
abnormal dystrophic nail bed retaining keratotic nail debris.

Bacterial infections:

Acute Paronychia: Acute paronychia usually results from local trauma to the nail
folds from an ingrown nail, nail biting, thorn prick, or from certain procedures like
manicure leading to pushing back of the cuticle. The infection starts in
the paronychium at the side of the nail with local redness, swelling and pain.

Chronic Paronychia: It is inflammatory dermatoses of the nail folds, with

secondary effects on the nail matrix; nail growth and soft-tissue attachments. The
dermatoses may be directly due to an irritant associated with wet work or caustic
materials. Wet cold hands are predisposed to chronic paronychia. It is
predominantly a disease of domestic workers, bar staff, canteen workers and
fishmongers. Most cases are between 30 and 60 years of age.

53
NAIL CHANGES IN ELDERLY62:

Characteristics Changes
color Yellow to gray with dull, opaque
appearance
Contour Increased transverse convexity
Decreased longitudinal curvature
Linear growth Decreases
Surface Increased friability with splitting and
fissuring Longitudinal furrows that are
superficial (onychorrhexis) and deep
(ridges)
Thickness Variable: normal, increased, or
decreased

OCCUPATIONAL NAIL DISORDERS:

Occupational nail diseases are abnormalities of one or more structures of the nail
apparatus, produced and/or aggravated by occupational factors. The occupation
must be a major factor in its causation.

Factors responsible for occupational Nail disorders are 63,64:

1. Trauma

2. Physical factors

3. Sensitizers

4. Wet work

54
5. Infections

6. Systemic absorption

1)Trauma: Acute injury in the nail unit of occupational onset may present as
partial or total hematoma (25% of the surface of the visible nail plate), lacerating
wounds. Onycholysis, dorsal pterygium, and split nail deformity are labelled as
delayed post-acute traumatic deformities. subungual hemorrhages have been
described among inexperienced male dishwashers using heavy rubber gloves and
are also frequently seen in sportsmen’s toes and in the toes of dancers65.
occupations involving vibrating power tools can lead to nail thickening,
brittleness, and splitting of the free edges.

2) Physical Factors: Burns, depending on severity, can lead to onycholysis,

disfiguring scars, pterygium, and fissured nails. prolonged exposure to cold may
result in injury to the nail matrix, leading to derangement of the nail plate ranging
from Beau’s lines to complete shedding.

3) Sensitizer: Irritants may find their way through nail plate or periungual skin
leading to contact dermatitis. “Tulip fingers” is a painful, dry, fissured,
hyperkeratotic eczema caused by contact with tulip bulbs and is seen in gardeners
and bulb growers66.

Among beauticians, occupational allergic dermatitis has been observed mostly in

young trainees who are not using gloves for work such as shampooing, applying
dye on hair, etc. A study evaluating contact dermatitis in beauticians by patch
testing revealed the following as the most common allergens on patch testing:

55
dyes, cold permanent wave primary solutions and a shampoo (1% aq.). Positive
reactions to allergens were seen with para-phenylenediamine (1% pet),
ammonium thioglycolate (5% aq.), paratoluenediamine (1% pet), para-
aminophenol (1% pet), ortho-aminophenol (1% pet), Quinoline yellow SS (0.5%
pet), nickel sulfate (2.5% pet), cobalt sulfate (2.3% pet), thimerosal (0.05% pet),
and procaine hydrochloride (1% pet) in decreasing order 67.

Cement dermatitis may be allergic, due to the dichromate content, or may result
from alkaline irritation and burns. Dermatitis of the dorsum of the proximal nail
fold and koilonychia are frequent. Epoxy resin dermatitis68, especially involves the
right first two fingertips, producing erosion and crusting or necrotic-appearing
lesions65.

3) Wet work: “wet work” is defined as individuals having their skin exposed to

liquids longer than 2 hours per day, or using occlusive gloves longer than 2 hours

per day, or cleaning the hands very often (e.g., 20 times/day or less if cleaning

procedure is more aggressive) or taking care of a less than 4-year-old child at

home. Sixteen occupations like laborers, food service workers, machine

operators, agricultural workers, health professionals, house cleaners, mechanics,

construction workers, and cosmetologists have extensive exposure to water 69.

4) Chemical irritants: Prolonged immersion of hands in water containing

concentrations of alkalis, alkaline chlorine-containing compounds, or powerful

56
detergents can lead to softening and gradual destruction of nail unit 70.5) 5)
Infections:

Bacterial infection: Even trivial trauma to the periungual skin may act as a portal
of infection leading to more severe conditions like cellulitis, erysipelas, and
streptococcal paronychia has been reported in workers in a chicken factory 71.

Diseases involving nail unit like Prosector’s wart (Mycobacterium tuberculosis),

swimming pool granuloma (Mycobacterium marinum), Tularemia inoculation by
coccobacillus Pasteurella tularensis65.

Fungal infections: Fungal infections of the nails and periungual region, especially
candidiasis, are a common occupational problem. hot, humid environmental
conditions prevailing in occupations like coal mining increase vulnerability to
developing dermatophytic toenail infections, with Trichophyton rubrum. Toenails
are 25 times more likely to be infected than fingernails as the causative molds are
ubiquitous fungi seen in soil, water, and decaying vegetations

Viral infections: Nail unit can be inoculated by viral warts, which are more
common in butchers, meat packers, poultry handlers, poultry processing workers,
and fish handlers, in whom many of the lesions are periungual or subungual64

57
 MATERIALS
AND METHODS

58
 MATERIALS AND METHODS

Present study titled “A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT

TERTIARY CARE HOSPITAL” was conducted from May 2021 to August 2022 in the
Department of Dermatology, Venereology and Leprosy at tertiary care hospital
after approval by Scientific Review committee and Human Research and ethics
Committee. (STU/ETHICS/Approval/10614/21).

• Study design: Cross-sectional Study.

• Study Area: Dermatology OPD of Tertiary care hospital.

• Study Period: May 2021 to August 2022(15 month).

• Sampling Technique: Convenient Purposive Sampling.

• Sample size and sampling methods:

➢ Sample size was 138 with 10% frequency at 95% Confidence Level

with 70,00,000 population.

• INCLUSION CRITERIA:

1) Patient age above 18 years.

2) Patients giving valid consent.

59
• EXCLUSION CRITERIA:

1) Patients age less than 18 yrs. of age.

2) Patients not giving valid consent.

3) Patient taking any kind of medications for nail disorders.

• METHODOLOGY:

➢ A cross sectional study was done in outpatient department of dermatology,

venereology & leprology at a tertiary care hospital.

➢ All patient fulfilling the inclusion and exclusion criteria are included.

➢ Valid inform written consent in vernacular language was taken. Participant

Information Sheet was given and Participant Informed Consent Form was

duly filled.

➢ A pre-structured proforma was used to collect the data.

➢ A detailed history of all the patients based on standard questionnaire was

taken and cutaneous examination of participant was done.

➢ Socio-demographic exposures variables like age, sex, occupation, education

etc. were collected.

➢ Personal history of Diabetes Mellitus, Hypertension, COPD, Bronchitis,

cardiovascular disorders& hyperthyroidism was taken.

60
➢ Investigations like Complete blood count including Hb estimation, TLC

Count, DLC Count, Gram stain, Urine examination, Liver function test, Renal

function test, Random blood sugar, KOH mount for Nail scrapping, Tzanck

smear and Nail Biopsy as and when required.

➢ All the cases were numbered serially and photographed whenever

necessary after taking valid consent.

• DATA ANALYSIS:

➢ Parameters like age, sex, socio-economic status etc. will be collected.

➢ Descriptive statistics like proportion, percentage and ratio will be calculated

for above variables using MS Excel.

➢ Chi-Square test has been used to find the significance of study parameters.

61
RESULTS

62
 RESULTS

Present study entitled “A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT

TERTIARY CARE HOSPITAL” was carried from May 2021 to August 2022 in
department of Dermatology, Venereology and Leprology at tertiary care hospital
after approval by Scientific Review Committee and Human Research and Ethics
Committee (STU/ETHICS/Approval/10614/21).

Table 1: Age and sex distribution of nail disorders (n=138)

Age in years Male No. (%) Female No. (%) Total (%)
21-30 9 (6%) 14 (10%) 23(16%)

31-40 32 (24%) 27 (19%)

59(43%)
41-50 23 (29.8%) 14 (22.9%) 37(28%)

51-60 9 (6.54%) 5 (3.5%) 14(10%)

>60 4 (2.8%) 1 (0.7%) 5(3%)

Total 77(56%) 61(44%) 138(100%)

In our study of 138 patients, 23(16%) cases were in age group of 21-30 years,
59(43%) cases were in 31-40 years, 37(28%) were in age group 41-50 years and
14(10%) were in 51-60 years and 5(3%) in age group of above 60 years.

63
 35
32

30
27

25 23
No. of Patients.

20

15 14 14

10 9 9

5
5 4
1
0
21-30 31-40 41-50 51-60 >60
Age in years.

males females

chart 1: Age and sex distribution of study.

The youngest patient was 21 years old and oldest patient was 72years of age. The
mean age of patients was 39 years.

64
Chart 2: Gender distribution of patients (n=138)

Female
44%

Male
56%

Male Female

In our study of 138 patients, 56% patients were males and 44% were females. The
male to female ratio was 1.26:1

65
Table 2: Occupational status (n=138)

Occupation Male No. (%) Female No. (%) Total No. (%)
Laborer 51(37%) 22(16%) 73(53%)
Household work 6(4.3%) 27(19.5%) 33(24%)
Services 13(9.35%) 11(8%) 24(17.3%)
Agricultural work 7(5.3%) 1(0.7%) 8(6%)
Total 77(56%) 61(44%) 138(100%)

In our study of 138 cases, 73(53%) cases were laborers, 33(24%) cases were of
household work, 24(17.3%) cases were of services, 8(5.8%) cases were of
agricultural work.

Agricultural
6%
Services
17%

Laborer
53%

Household work
24%

Laborer Household/domestic help Services Agricultural

Chart 3: Occupational distribution.

Majority of cases in our study were laborer and household workers.

66
Table 3: Educational status (Indian standard classification of education)72
(n=138)

Educational status Male No. (%) Female No. (%) Total No. (%)
Illiterate 16(11%) 7(5%) 23(16%)
Primary 6(4%) 3(2.25%) 9(6.25%)
Secondary/higher secondary 30(22%) 31(20.2%) 61(44.2%)

Graduate/post graduate 25(18%) 20(15%) 45(33%)

Total 77(56%) 61(44%) 138(100%)

Classification of education according to Indian standard classification of education

by government of india under ministry of human resource devlopment 72.

Illiterate
17%
Graduate/post
graduate
33% 5th pass
6%

Secondary/higher
secondary
Illiterate 5th pass Secondary/higher secondary
44% Graduate/post graduate

Chart 4: Educational status

Acoording to In our study of 138 cases, majority(61%) cases had secondary/higher
secondary education,45(33%) cases were graduates/post graduates,23(16.6%)
were illitrate and 9(6.25%) cases had primary education only.

67
 Table 4: Socioeconomic status (Modified Kuppuswamy Scale 2022)73 (n=138)
Socioeconomic status Males No. (%) Female No. (%) Total No. (%)
Lower 53 (38%) 36(26%) 89(64%)

Lower middle 19 (14%) 21 (15%) 40(29%)

Upper middle 5 (4%) 4 (3%) 9(7%)

Total 77(56%) 61(44%) 138(100%)

Socioeconomic status classification according to Gunjan K et al, Socioeconomic

status scale-Modified Kuppuswamy scale for year 202273.

60
53
50
Socioeconomic status

40 36

30
21
19
20

10 5 4

0
Lower Lower middle Upper middle

Male Female

chart 5: Socioeconomic distribution of study.

Out of 138 cases, 89(64%) cases were in lower socioeconomic status, 40(29%)
cases were in lower middle and 9(7%) cases were in upper middle socioeconomic
status. There was no patient from upper class.

68
Table 5: No. of nail involved (n=138)

No. of Nails involved No. of cases Percentage

1-5 89 64.4%
6-10 35 25.36%
11-15 10 7.2%
16-20 4 2.8%
Total 138 100%

In our study of 138 cases, no. of nail involved in individual cases was 1-5 in

89(64.4%) cases, 6-10 in 35(25.36%) cases,11-15 in 10(7.2%) cases, 16-20 in

4(2.8%) cases.

Table 6: Site of involvement of nails (n=138)

Nail involved No. of cases Percentage
Finger nails only 75 54.3%
Toe nails only 25 18.1%
Both finger& toenails 38 27.5%
Total 138 100%

In our study of 138 patients, 75(54.3%) cases had only fingernail involved,

38(27.5%) had both finger nails & toenails involved 25(18.1%) had only toenails

involved.

69
Table 7: Spectrum of nail disorders (n=138):

S. No. Nail Disease No. of Cases Percentage

1 Onychomycosis 47 34%
2 Nail psoriasis 21 15.2%
3 Paronychia 12 8.68%
4 Lichen planus 10 7.24%
5 Clubbing 6 4.34%
6 Eczema 5 3.62%
7 Beau’s line 5 3.6%
8 Ingrown toe nail 4 3%
9 Alopecia areata 4 3%
10 Pincer nail 4 3%
11 Geno-dermatoses 4 3%
12 Yellow nail 3 2.1%
13 Koilonychia 3 2.1%
14 Periungual wart 3 2.1%
15 Onychogryphosis 2 1.44%
16 Muercke’s line 2 1.44%
17 Acropustulosis 1 0.72%
18 Thyroid acropachy 1 0.72%
19 Onychomadesis 1 0.72%
Total 138 100%

In our study of 138 cases, 47(34.1%) cases were of onychomycosis, 21(15.2%)

cases belong to psoriasis, 12 (8.68%) cases were of paronychia,10 (7.24%) cases
of lichen planus,6(4.34%) cases of clubbing.

There were 5(3.7%) cases each of eczema and Beau’s lines.

70
There were 4(3%) cases each of ingrown toe nails, pincer nails, alopecia areata

and genodermatoses.

There were 3(2.1%) cases each of yellow nails, pterygium, koilonychia,

periungual wart.

There were 2(2.1%) cases each of onychogryphosis and Muercke’s line.

There were 1(0.72%) case each of thyroid acropachy, acropustulosis,

onychomadesis were enrolled.

71
Table 8: Different morphological nail changes in study (n=185)
S.no. Nail changes No. of cases percentages
1 Onychomycosis 47 25%
2 Pitting 23 12.4%
3 Onycholysis 10 5.4%
4 Ragged cuticle 10 5.4%
5 Transverse grooves 9 5%
6 Nail fold inflammation 8 4.34%
7 Clubbing 6 3.24%
8 Subungual hyperkeratosis 5 2.7%
9 Nail dystrophy 5 2.7%
10 Trachyonychia 5 2.7%
11 Koilonychia 5 2.7%
12 Beau’s lines 5 2.7%
13 Twenty nail dystrophy 4 2.1%
14 Longitudinal Melanonychia 4 2.1%
15 Pincer nails 4 2.1%
16 Ingrown toe nails 4 2.1%
15 Pterygium 3 1.6%
16 Longitudinal ridging 3 1.6%
17 Yellow nails 3 1.6%
18 Periungual wart 3 1.6%
19 Onychogryphosis 2 1.08%
20 Leukonychia 2 1.08%
21 Splinter hemorrhage 2 1.08%
22 Salmon patch 2 1.08%
23 Nail plate thinning 2 1.08%
24 Muercke’s line 2 1.08%
25 Onychomadesis 1 0.54%
26 Racquet nails 1 0.54%
27 Median dystrophy of Heller 1 0.54%
28 Pachyonychia congenita 1 0.54%
29 Darier’s disease 1 0.54%
30 Thyroid acropachy 1 0.54%
31 Acropustulosis 1 0.54%
Total 185 100%

72
In our study, multiple conditions were present in single patient and single
condition present in multiple nail disorders. So, total 185 nail changes found in
138 patients.

Table 9: Association of nail changes with cutaneous and systemic conditions

(n=138).

Association of nail changes No. of cases percentage

with cutaneous conditions 87 63%
with systemic diseases 28 20%
Only nail changes 23 17%
Total 138 100%

In our study of 138 cases having nail changes, 87(63%) cases had associated
cutaneous conditions,28(20%) cases had associated systemic conditions and
23(17%) cases had only nail changes without any association.

Table 10: Cutaneous conditions associated with nail changes. (n=87)

Cutaneous conditions Male Female Total no. (%)

Dermatophytoses 18 17 35(40.2%)
Psoriasis 11 10 21(24.13%)
Lichen planus 6 4 10(11.4%)
Paronychia 3 3 6(7%)
Eczema 4 1 5(5.74%)
Alopecia areata 2 2 4(4.5%)
Periungual wart 2 1 3(3.44%)
Pustular psoriasis 0 1 1(1.14%)
Darier’s disease 1 0 1(1.14%)
Pemphigus vulgaris 0 1 1(1.14%)
total 47 40 87(100%)

73
In our study, 87(63%) cases had cutaneous conditions. Out of which, 35(40.2%)
cases were of onychomycosis with dermatophytic infection, 21(24.13%) cases had
nail psoriasis, 10(11.4%) cases had lichen planus, 6(7%) cases had paronychia,
5(5.74%) had eczema, 4(4.5%) cases had alopecia areata, 3(3.44%) cases had
periungual wart, 1(1.14%) case each of pustular psoriasis, Darier’s disease,
pemphigus vulgaris.

Table 11: Nail changes along with systemic conditions (n=28)

Nail diseases Male Female Total no. (%)
Paronychia 2 4 6(21.4%)
Clubbing 4 2 6(21.4%)
Beau’s lines 2 1 3(10.7%)
koilonychia 3 0 3(10.7%)
Yellow nails 2 1 3(10.7%)
Onychogryphosis 1 1 2(7.14%)
Muercke’s line 1 1 2(7.14%)
Onychomycosis 2 0 2(7.14%)
Thyroid acropachy 1 0 1(3.5%)
Total 18 10 28(100%)

In our study of 138 cases, 28(20%) patients had systemic disease, out of which
6(21.4%) case each of paronychia and clubbing, 3(10.7%) cases each were of
Beau’s lines, koilonychia, yellow nails, 2(7.14%) cases each were of
onychogryphosis, Muercke’s lines, onychomycosis and 1(3.5%) case were of
Grave’s disease.

74
Table 12: Nail changes without any association (n=23)

Nail changes Male Female Total no. (%)

Onychomycosis 7 3 10(43%)
Pincer nails 2 2 4(17.3%)
Ingrown toe nails 0 4 4(17.3%)
Genodermatoses 1 2 3(13%)
(racquet nails, median
dystrophy of Heller,
pachyonychia congenita)
Beau’s lines 2 0 2(8.69%)

Total 12 11 23(100%)

In our study of 138 cases, 23 cases had only nail changes without any cutaneous
and systemic diseases. Out of which 10(43%) cases were of
onychomycosis,4(17.3%) cases each of ingrown toe nails and pincer nails,3(13%)
cases were of genodermatoses,2 (8.69%) cases were of Beau’s lines.

75
Table 13: Types of onychomycosis (n=47)
Type No. of cases percentage
Distal and Lateral subungual 39 82.97%
onychomycosis (DLSO)

White Superficial subungual 3 6.5%

onychomycosis (SWO)
Proximal superficial onychomycosis (PSO) 2 4.25%

Total dystrophic onychomycosis (TDO) 3 6.5%

Total 47 100%

In our study,47 patients had onychomycosis, 39(82.97%) had distal and lateral
subungual onychomycosis (DLSO), 3(6.5%) had white superficial onychomycosis
(SWO), 3(6.5%) had total dystrophic onychomycosis (TDO), 2(4.25%) had proximal
subungual onychomycosis (PSO).

Table 14: Age & sex wise distribution of onychomycosis(n=47)

Age group Male Female Total (%)
21-30 2 6 8(17%)
31-40 13 6 19(40.4%)
41-50 5 6 11(23.4%)
51-60 4 2 6(12.7%)
>60 3 0 3(6.3%)
Total 27 20 47(100%)

76
 Out of 47 patients, majority of patients 19(40.4%) cases were of age group 31-40
yrs., 11(23.4%) were of 41-50 yrs. 11(23.4%),8(17%) was of 20-30 yrs. 6(12.7%)
were of 51-60 yrs. and 3(6.3%) were of >60 yrs.

14 13

12

10

8
6 6 6
6 5
4
4 3
2 2
2
0
0
21-30 31-40 Male41-50Female 51-60 >60

Chart 6: Age and sex distribution of onychomycosis

Out of 47 cases, 27(57.4%) were males and 20(42.5%) were females.

Table 15: Onychomycosis and gender correlation(n=47):

Gender Onychomycosis Total
Present Absent
Male 27 50 77
Female 20 41 61
Total 47 91 138

77
 In our study, 27 male and 20 female cases had onychomycosis. On applying chi-

square test, no statistically significant association found between onychomycosis

and gender (chi-square statistic is 0.078 and p-value is 0.77)

Table 16: Onychomycosis according to site of involvement (n=47):

Site of DLSO PSO SWO TDO Total
involvement No. (%)
Fingernails only 17 2 1 1 21(44.7%)
Toenails only 8 0 1 1 10(21.2%)
Both fingernails 14 0 1 1 16(34%)
and toe nails
Total 39 2 3 3 47(100%)

In our study, 47 cases had onychomycosis, out of which 21 (44.7%) had only finger

nail involvement, 16(34%) had both fingernails and toenails involvement and

10(21.2%) had only toe nail involvement.

18

16

14

12

10

0
DLSO PSO SWO TDO
Fingernails only Toenails only Both finger& toe nails

Chart 7: Site of nail involvement.

78
 In onychomycosis, fingernails were more commonly involved then toenails.

Table 17: Onychomycosis and socioeconomic status distribution (n=47):

Socioeconomic Onychomycosis Total

Status Present Absent
Lower class 33 56 89
Middle class 14 35 49
Total 47 91 138

In our study, 89 cases were from lower class and 49 cases were from middle class.

On applying chi-square test, no statistically significant association found between

onychomycosis and socioeconomic status (chi-square statistic is 1.01 and p-value

is 0.31)

Out of 47 cases of onychomycosis, KOH mount was positive in 28(59.5%) cases.

Table: 18 Occupational distribution in cases of onychomycosis (n=47)

Occupation No. of cases Percentage

Laborer 32 68%
Household work 8 17%
Services 3 6.4%
Agricultural 4 8.5%
Total 47 100%

79
Out of 47 cases of onychomycosis, 32(68%) cases were laborer, 8(17%) cases were
of household work, 3(8.5%) cases were of agricultural work and 3(6.4%) cases
were of service work.

Table:19 Co-relation between onychomycosis and occupational status (n=138):

Occupation Onychomycosis Total
Present Absent
Laborer 32 41 73
Others 15 50 65
Total 47 91 138

Out of 138 cases, 73 cases were laborers and 65 cases belongs to other
occupation. On applying chi-square test, a significant association was found
between onychomycosis and laborer class. (chi-square statistic is 6.5 and p-value
<0.01)

Table 20: Age & sex distribution of psoriasis (n=21)

Age group Male Female Total No. (%)
21-30 2 1 3(14.2%)
31-40 2 6 8(38%)
41-50 4 3 7(33.3%)
51-60 3 0 3(14.2%)
Total 11 10 21(100%)

80
In our study 21 cases had psoriasis. Out of which, 8(38%) cases were of age group

31-40 yrs., 7(33.3%) were of 41-50 yrs., 3(14.2%) cases each of age group 21-30

yrs. and 51-60 yrs.

6
6

4
No. of cases

3 3
3

2 2
2

1
1

0
0
21-30 31-40 41-50 51-60
Age group

Chart 8: Age and sex distribution among psoriasis.

Out of 21 cases of psoriasis, 11(52%) were males and 48% cases were females.

81
Table 21: Pattern of nail changes in psoriasis (n=21):
Pattern of nail changes No. of cases Percentage
Pitting 20 95.23%
Subungual hyperkeratosis 4 19%
Onycholysis 4 19%
Discoloration 3 14.28%
Leukonychia 2 9.5%
Splinter hemorrhage 2 9.5%
Salmon patch 2 9.5%
Twenty nail dystrophy 1 4.76%

In our study 21 patients had psoriasis, 20(95.23%) cases had pitting, 4(19%) had

subungual hyperkeratosis,3(14.28%) had discoloration, 2(9.5%) each had

leukonychia, splinter hemorrhage, salmon patch, 1(4.76%) had twenty nail

dystrophy.

Table 22: According to site of nail involvement in psoriasis: (n=21):

Nail affected No. of cases Percentage
Fingernails only 6 28.5%
Toenails only 3 14.3%
Both fingernails &toe nails 12 57.1%

Out of 21 cases of psoriasis,12(57.1%) cases had both fingernails and toenails

involved 6(28.5%) had only fingernails involvement and 3(14.3%) had only

82
toenails involved. 18(85.6%) cases had total fingernails involved and 15(71.4%)

had total toenails involved.

Table 23: Pattern of nail changes in paronychia (n=12):

Nail changes No. of cases Percentage

Ragged cuticle 10 83.3%
Transverse grooves 9 75%
Nail fold inflammation 8 66.6%
Nail dystrophy 5 42%

In our study of138 cases, out of 12 cases, 8(66.6%) cases were age group 31-40
yrs. and 3(25%) cases were in 41-50 yrs. 1 (8%) case were in 61-70 yrs. The male:
female was 1:1.4. Out of 12 cases, 10(83.3%) had ragged cuticle,9(75%) had
transverse grooves, 8(66.6%) had nail fold inflammation and 5(42%) had nail
dystrophy.

Table:24 Site of nail changes in paronychia (n=12).

Nail involved No. of cases percentage

Fingernails only 8 66.6%
Toenails only 2 16.6%
Both fingernails and toenails 2 16.6%

In our study, 12 cases had paronychia. Out of which 8(66.6%) cases had fingernails
involvement only while 2(16.6%) cases each of toenails, both toe and fingernails.

83
Table 25: Association of paronychia with diabetes mellitus (n=13).

Associated diseases Diabetes present Diabetes absent Total

Paronychia present 6 6 12
Paronychia absent 7 119 126
Total 13 125 138

Out of 12 cases of paronychia, 6 cases had diabetes. On applying chi-square test,

statistically significant association was found between diabetes mellitus and
paronychia (chi-square statistic is 25.363 with p-value <0.00001).

Table 26: Pattern of nail involvement in lichen planus (n=10)

Pattern of involvement No. of cases Percentage

Pterygium
Longitudinal melanonychia
Nail plate thinning
Longitudinal ridging
Onycholysis
Subungual hyperkeratosis
Trachyonychia
Twenty Nail dystrophy
3 30%
2 20%
2 20%
2 20%
2 20%
1 10%
1 10%
1 10%

In our study of 138 cases, 10(7.24%) patients had lichen planus. Amongst them
3(30%) had pterygium,2(20%) each had longitudinal ridging and nail plate
thinning, 1(10%) each had longitudinal melanonychia, subungual hyperkeratosis
and trachyonychia.

84
Table 27: Pattern of nail changes in eczema (n=5):

Pattern of involvement No. of cases Percentage

Trachyonychia 3 60%
Melanonychia 2 40%
Onycholysis 2 40%
Pitting 1 20%
Longitudinal striations 1 20%
Nail fold erythema 1 20%

In our study of 138 patients, 5(3.62%) had eczema.2(40%) patients belong to 41-
50 yrs. age group.1(20%) case each belongs to 31-40Yrs,.51-60 yrs. and 61-70yrs.

Out of 5 cases of eczema, 3(60%) cases had trachyonychia, 2(40%) had

melanonychia and onycholysis,1(20%) each had pitting, longitudinal striations,
nail fold erythema.

Table 28: Pattern of nail changes in alopecia areata (n=4):

Pattern of nail involvement No. of cases Percentage

Pitting 3 75%
Onycholysis 2 50%
Longitudinal striations 1 25%
Trachyonychia 1 25%

In our study of 138 cases, 4(4.28%) had alopecia areata. Out of them 3(75%)
patients belong to 31-40 yrs.,1(25%) patient belongs to age group 21-30 yrs.

85
Pitting is seen in 3(75%) of cases, onycholysis is seen in 2(50%) cases, longitudinal
striations and trachyonychia seen in 1(25%) case each.

Table 29: Pitting and its associated diseases (n=24):

Associated disease Male Female Total no. (%)
Psoriasis vulgaris 10 10 20(83.3%)
Alopecia areata 2 1 3(12.5%)
Eczema 1 0 1(4.2%)
Total 13 11 24(100%)

In our study, 24 patients had pitting. Out of which, 83.3% cases were of psoriasis

vulgaris, 12.5% cases were of alopecia areata, 4.2% cases were of eczema .

Table 30: Association of pitting with skin diseases (n=24):

Cutaneous Pitting present Pitting absent Total

involvement
Psoriasis vulgaris 20 1 21
Other disease 4 113 117
Total 24 114 138

Out of 24 cases of pitting, 20 cases of pitting had psoriasis vulgaris and 4 cases
had other diseases. On applying chi-square test, statistically significant association
found between pitting and psoriasis vulgaris. (chi-square statistic 104.4807 and p-
value < 0.00001).

86
Table 31: Onycholysis associated with underlying dermatoses (n=10):

Associated disease Male Female Total no. (%)

Psoriasis Vulgaris 3 1 4 (40%)
Lichen Planus 1 1 2 (20%)
Eczema 1 1 2 (20%)
Alopecia Areata 2 0 2 (20%)
Total 7 3 10(100%)

In our study 10 cases had onycholysis, out of which 4(40%) cases were of psoriasis
vulgaris, 2(20%) cases each of lichen planus, eczema, alopecia areata.

Table 32: Trachyonychia associated with underlying dermatoses (n=5)

Associated Male Female Total (%)
Disease
Eczema 2 1 3(60%)
Lichen Planus 1 0 1(20%)
Alopecia Areata 0 1 1(20%)
Total 3 2 5(100%)

Out of 5 patients of trachyonychia, 3(60%) patients had eczema, 1(20%) patient

had lichen planus, 1(20%) patient had alopecia areata.

87
Table 33: Systemic conditions with nail diseases. (n=28).

Etiology Systemic condition No. of patients

Infective HIV 1
Typhoid 1
Dengue 1
Tuberculosis 1

Respiratory Anemia of chronic disease 1

Asthma 1
Chronic bronchitis 1
Acute pneumonia 1
Endocrine DM 12
DM with hypertension 1
Grave’s Disease 1
Hematological Iron deficiency anemia 4
Anemia of chronic disease 1
Renal CRF on dialysis 1
Carcinoma Breast carcinoma on 1
chemotherapy
Total 28

In our study of 138 cases, 13(9.42%) had diabetes mellitus,4(3%) had iron
deficiency anemia and 1(0.72%) each were of twelve different systemic
conditions.

88
Table 34: Distribution according to nail changes in diabetes mellitus (n=13).

Nail changes No. of cases Percentage

Chronic paronychia 4 31%
Yellow nails 3 23%
Acute paronychia 2 15.3%
Onychomycosis 2 15.3%
Onychogryphosis 2 15.3%
Total 13 100%

In our study, 13 cases had diabetes mellitus, out of which 4(31%) had chronic
paronychia, 3(23%) had yellow nails, 2(15.3%) each had acute paronychia,
onychomycosis and onychogryphosis.

Table:35 Distribution of clubbing according to systemic diseases (n=6)

Systemic disease Male Female Total No. (%)

Iron deficiency anemia 1 1 2(33.3%)
Chronic bronchitis 1 0 1(16.6)
Anemia of chronic disease 1 0 1(16.6%)
TB 0 1 1(16.6%)
Asthma 1 0 1(16.6%)
Total 4 2 6(100%)

89
6(4.34%) cases had clubbing with male: female was of 2:1. Out of which, 2(33%)
cases due to Iron deficiency anemia, 1(16.6%) case each of chronic bronchitis,
anemia of chronic disease, tuberculosis, and asthma.

➢ 5(3.62%) cases had Beau’s lines, out of which, one (20%) case due to
trauma, dengue fever, typhoid fever, chemotherapy patient of breast
carcinoma, idiopathic each.

➢ 3(2.17%) cases of koilonychia, out of which,2 (66.6%) iron deficiency anemia

and 1(33.3%) case with acute pneumonia.

➢ 2 cases of Muercke’s line were enrolled. Out of which one (50%) case each
due to HIV and chronic renal failure.

➢ 1(0.72%) case of Grave’s disease had thyroid acropachy.

90
DISCUSSION

91
 DISCUSSION

Present study entitled “A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT

TERTIARY CARE HOSPITAL” was carried from May 2021 to August 2022 in
department of Dermatology, Venereology and Leprology at tertiary care hospital
after approval by Scientific Review Committee and Human Research and Ethics
Committee (STU/ETHICS/Approval/10614/21).

Total 138 cases of nail disorders were enrolled in this study. Out of 138 cases

77(56%) were males and 61(44%) were females.

Age & Sex distribution of nail disorders:

In our study, most of patients (43%) were among the age group of 31-40 yrs.

while study of Rani et al74 demonstrated that 22.3% cases were among 31-40 yrs.

age group. In our study majority of cases (59%) comes under 20-40 yrs. age group.

In Neerja puri et al75 study 40% cases were among 21-40 yrs. age group.

In our study, youngest patient was of 20 yrs. and oldest patient was of 72 yrs.

while in Rani et al74 youngest patient was of 1 yr. and oldest was of 86 yrs. This

disparity could be explained as our study had enrolled only patients age of >18

yrs.

92
In our study, male to female ratio was 1.26:1 which is comparable to Bansal Goyal

N et al76 male: female was 1.29:1. According to study of Rani et al74 male: female

was 0.8:1 whereas study of Neerja puri et al75observed male: female of 1.08:1.

Occupation status:

In our study, majority of cases were laborer (53%) followed by household (24%)

while Neerja puri et al75 had observed more housewife (34%) and laborer (24%).

This could be explained as our city is heavily industrialized so, the no. of migrant

population is more.

Educational status:

Out of 138 cases, majority 44.2% cases had secondary/higher secondary

education, 33% cases had done graduation/postgraduation, 16.6% cases were

illiterate and 6.25% cases had only primary education. According to Gujrat NFHS-5

factsheet77 95% of men and 86% of women were literate in urban area while in

our study,79% male and 89% female were literate, which may be due to migration

of illiterate male laborer.

Socioeconomic status:

In our study majority of patients 89(64%) were in lower socioeconomic status

class, 40(29%) cases were in lower middle and 9(7%) were in upper middle class.
93
There was no patient of upper class in our study. This could be explained as many

patients attending to OPD were of lower and middle class.

No. of nail involved:

In our study, 64.4% Patients had 1-5 no. of nails affected followed by 25.36% had

6-10 no. of nails affected followed by 7.2% had 11-15 no. of nails affected

followed by 2.8% had 16-20 no. of nails affected. But according to Neerja puri et

al75 35% patients had 1-5 nail involved followed by 38% patients had 6-10 no. of

nail involved followed by 18% had 16-20 no. of nails involved. It could be due to

large sample size of their study and longer study duration.

Site of involvement of nails:

In our study, 54.3% patients had only fingernails involved followed by 27.5% both

fingernails & toenails and 18.1% patients had only toe nail involved but according

to Garg et al78 study 60% has fingernails involved followed by 26.67% had toenails

involved and both fingernails and toenails involved in 13.34% cases.

Spectrum of nail involvement:

In our study, 34% cases had onychomycosis, 15% had psoriasis with nail

involvement and 8.64% cases had paronychia. These three conditions constitute

nearly 57% cases in our study, which is comparable to Neerja puri, et al75 study

94
and Bansal N, et al76 study shows 53% and 57% cases respectively of above-

mentioned conditions.

Longitudinal Melanonychia:

In present study, 3% cases had longitudinal melanonychia and all of them were

male. Out of total cases of melanonychia, 50% each were associated with lichen

planus and eczema. Collins RJ et al79 stated that most common cause of

melanonychia is racial variations and was commonly seen in Afro-Caribbean over

the age of 20. Sharma S et al80, demonstrated longitudinal melanonychia with

longitudinal ridging and splitting are commonest finding of lichen planus.

Ingrown Toe nails:

In our study, 3% cases were of ingrown toe nails amongst which most of cases

were industrial workers wearing tight-fitting safety shoes. According to cambiaghi

S et al81 demonstrated that main cause of ingrown toe nails is tight-fitting

footwears.

Pincer Nails:

In our study, 3% cases had pincer nails. According to study of Baran et al82 pincer

nail was due to tight fitting shoes and trauma.

95
Wart:

In our study, 2.17% cases had periungual wart. All cases were associated with

verruca vulgaris, so periungual wart may had developed as a pseudo-Koebner

phenomenon. According to study of de berker Dar et al10 observed that

subungual warts are the most common tumor involving nail apparatus.

Acropustulosis:

One female patient of pustular psoriasis with history of recurrent episodes of

acropustulosis presented with anonychia of thumb and middle finger nail of both

hands. According to Pirraccinni et al,83in his study most of the patients had single

digit involvement and a few patients had more than one digit involvement.

Onychomadesis:

One female patient of pemphigus vulgaris with onychomadesis involving ring

finger, middle finger, index finger of left hand. According to Schlesinger et al84, in

his study of 64 patients of pemphigus vulgaris, Chronic paronychia (60%) was the

most common manifestation followed by onychomadesis (33%) of cases.

96
Cutaneous condition associated with nail changes:

In our study, 63% cases had different cutaneous conditions while Rani et al74

study demonstrated nail changes associated with cutaneous conditions in 45%

cases.

Nail changes along with systemic conditions:

In our study, 20% cases had systemic diseases which is comparable to Rani et al74

study observed 17.83% cases had systemic diseases.

Nail changes without any association:

In our study, 17% cases had no association while Rani et al74 observed 38% cases

had no association.

Types of onychomycosis:

In present study, majority of patients (82%) of onychomycosis were of DLSO type,

6.5% had SWO type, 6.5% had TDO followed by 4.2% had PSO type. whereas

Grover S, et al85 demonstrated DLSO in 82% cases, PSO in 6% and TDO in 6%

which is comparable to our study. In Rani et al74 62.86% patients had DLSO type

and TDO type was observed in 31.43% cases. Garg et al,78 reported DLSO in 64.4%

cases, PSO in 4.4%, TDO in 17.6%.

97
Age &sex distribution of onychomycosis:

In our study, 34% cases had onychomycosis with male: female ratio of 1.35:1. This

is the most common nail finding in our study. In the study by Rani et al74 21.87%

cases had onychomycosis. In our study, 57.4% cases of onychomycosis belonged

to 20-40 yrs. age group which is comparable to Rani et al74 study which showed

51.4% cases in this age group.

Onychomycosis and gender correlation:

There was no statistically significant association between onychomycosis and

gender.

Onychomycosis according to site of involvement:

Fingernails were most involved in 44.7% cases in our study while in Rani et al74

study fingernails were involved in 54.1% cases.

Onychomycosis and socioeconomic status correlation:

There was no significant association of onychomycosis with socioeconomic status.

KOH MOUNT:

KOH mount was positive in 59% cases. which is comparable to Manjunath, et al86

study KOH mount was positive in 53% cases. According to Bansal Goyal N et al76

98
study KOH mount was positive in 71% cases and in study of Blake N et al87 KOH

mount was positive in 43.5% cases.

Occupational distribution in case of onychomycosis:

In our study, majority of patients 68% cases were laborer and 17% cases were of

household work while Rani et al74, study demonstrated majority of patients were

laborer (37.14%) and house wives (34.28%). This could be explained as our city

has more no. of industries.so, the no. of migrant workers are more in our city.

Correlation between onychomycosis and occupational status:

Our study found a significant association between onychomycosis and laborer

class.

Age and sex distribution of psoriasis:

In our study, 15.2% patients had nail psoriasis. The most common age group

affected was 31-40 yrs. while in study of Rani et al74, the most common age group

was 41-50 yrs.

Pattern of nail changes in psoriasis:

Pitting is most common finding observed in 95% of cases followed by onycholysis

in 19% discoloration (14.28%), splinter hemorrhage in 9.5% and twenty nail

99
dystrophy 4.76%. According to study of Ghosal A, Gangopadhyay et al88 pitting

(90.23%) was the most common fingernail change observed which is comparable

to our study. According to study of Kaur et al89 pitting was observed in 72.5%.

According to site of involvement in psoriasis:

In our study, fingernails (85.6%) most involved which is comparable to study of

Ghosal A, Gangopadhyay et al88 showed 88.8% cases had fingernails involved.

Age &sex distribution in paronychia:

In our study, paronychia was observed in 12(8.69%) cases. Out of which 6(50%)

cases were housewives. Tosti et al90 and Morten RH et a91 have concluded that

chronic paronychia is predominantly a disease of household workers.

Majority of cases were in age group of 31-60 yrs. with male: female of 1:1.4 which

is comparable to Esteves J et al92, reported that majority of cases of paronychia

occurred in the age group of 30 to 60 years.

Pattern of nail changes in paronychia:

In our study, most common finding in paronychia is ragged cuticle seen in 83%

cases while Neerja puri et al75, demonstrated ragged cuticle in 100% cases.

100
Site of nail changes in paronychia:

In our study paronychia was observed more in fingernails (83.3%) which is

comparable to Rani et al74, study had 82.4% fingernails involved.

Association of paronychia with diabetes mellitus:

In our study statistically significant association was found between diabetes

mellitus and paronychia. Yesudian et al93 demonstrated the same.

Pattern of nail changes in lichen Planus:

In present study, 7.24% cases had nail changes associated with lichen planus,

among these, pterygium was observed in 40% cases. According to Nakamura R et

al94, pterygium was demonstrated in 21% cases. According to Francesco et al95

thinning, ridging and longitudinal striations were the commonest presentations.

Pattern of nail changes in eczema:

In present study 3.6% cases had nail changes associated with eczema. Among

these, trachyonychia was observed in 60% cases followed by onycholysis in 20%

cases & pitting was observed in only one case. According to study of de Barker

DAR et al10 which quoted that hand eczema is one of the causes for onycholysis

and nail pitting.

101
Pattern of nail changes in alopecia areata:

In present study, 4.28% cases had nail changes associated with alopecia areata. In

75% cases nail pitting was the most common finding. According to study of

Gandhi V, Baruah MC et al96 the common abnormality observed was superficial

pits seen in 64% of patients.

Pitting and its associated diseases:

In present study of 138 patients, 24(17.83%) patients had pitting. Out of total

cases of pitting, 83.3% cases were of psoriasis vulgaris, 12.5% cases were of

alopecia areata, 4.2% cases were of eczema .

Association of pitting with skin diseases:

Our study found statistically significant association between pitting and nail

psoriasis which is comparable to study of Bansal Goyal N, et al76.

Onycholysis associated with underlying dermatoses:

Out of 7.24% cases of onycholysis with different dermatoses. Majority (40%) cases

associated with psoriasis. Zaias N et al 97demonstrated that psoriasis vulgaris and

pustular psoriasis are the most common disease producing onycholysis. Our study

shows the same.

102
Trachyonychia associated with underlying dermatoses:

Trachyonychia was observed in 3.63% cases. Out of which, 60% cases were from

eczema followed by 20% from lichen planus 20% from alopecia areata. Study of

Tosti A et al98 demonstrated the association of trachyonychia with alopecia

areata, lichen planus, eczema.

Nail changes related to Genodematoses:

3% cases of genodermatoses were reported in present study which includes single

(0.7%) cases each of racquet nails, pachyonychia congenita, medial dystrophy of

Heller and Darier’s disease.

• Racquet Nails: It was observed in a 26 yr. old male involving both thumbs

only. According to Baran et al99study, racquet nail shows autosomal

dominant inheritance, which involve mostly thumbs followed by fingers.

• Pachyonychia Congenita: It was observed in a 23 yr. old female involving all

her finger nails and toe nails and hoarseness of voice and natal teeth. There

was family history of similar complaint in her sibling. According to study of

Sarojini PA et al100 and Sivasundaram et al 101 which states that

pachyonychia congenita is an autosomal dominant inherited disease. PC-1

103
 or Jahassen-Lewandowsky is commonest type. In our study pachyonychia

congenita belongs to Jackson- Lawler (PC-2) type.

• Darier’s disease: It was observed in a 27 yr. old male involving left and right

middle fingers shows V-shaped notching. According to Zaias N et al102

stated that distal subungual wedge shape keratosis with red and white

streaks are diagnostics of Darier’s disease.

• Median nail dystrophy of Heller: It was observed in a 22 yr. old female

affecting left thumb and left great toe. According to study of Pathania V et

al103 median nail dystrophy of Heller due to repetitive trauma to nail plate

and cuticle.

Systemic conditions with nail changes:

In present study 9.42% had diabetes mellitus,3% had iron deficiency anemia and
0.72% each were of twelve different systemic conditions. Which is comparable to
Rani et al74 study which demonstrated majority of cases among systemic diseases
were of diabetes mellitus.

Distribution according to nail changes in diabetes Mellitus:

Out of 13 case of diabetes mellitus,6(46%) cases had paronychia and our study

found a significant association in between the two. 2(15.38%) cases of

104
onychomycosis had diabetes. Trovato et al104, demonstrated that diabetic

patients were more predisposed to onychomycosis.

Out of 13 cases of diabetes, 3(23.07%) cases had yellow nails. Vidyasagar and

Kumar et al105 study demonstrated that diabetes and fungal infections were major

causes for yellow nails.

2(15%) cases had onychogryphosis had great toes involvement. According to

Gilchrist AK et al106study onychogryphosis occur in mostly great toe nails. It could

be due to local trauma mostly tight-fitting shoes.

Distribution of clubbing according to systemic diseases

4.34% cases had clubbing, out of which, 33.3% cases due to Iron deficiency

anemia, 16.6% case each of chronic bronchitis, anemia of chronic disease,

tuberculosis, asthma. According to study of Baran R& Dawber RPR10, the cause of

clubbing is thoracic organ disorders followed by alimentary and other causes.

Beau’s Line:

Out of 3.62% cases had Beau’s line, out of which, 20% case each due to trauma,

chemotherapy of breast carcinoma, typhoid, dengue and idiopathic. Saraswat N

et al107 study observed Beau’s lines were one of commonest manifestations of

chemotherapy.

105
Koilonychia:

2.17% cases had koilonychia and all were males. Out of which, 66% cases were

associated with iron deficiency anemia and 34% case associated with pneumonia.

According to study of Bergaron JR et al 108 which states that iron deficiency

anemia is the most common cause of koilonychia. Our study shows the similar

findings.

Muercke’s line:

1.44% cases had Muercke’s lines, out of which 0.72% of each had chronic renal

failure and HIV. Singh G et al109, study demonstrated chronic hypoalbuminemia

either due to chronic renal failure and glomerulonephritis is the main cause of

Muercke’s line.

Grave’s disease and associated finding:

In our study, one 47 yrs. old patient of Grave’s disease with nail clubbing and

swelling of digits (thyroid acropachy) was enrolled. According to Fatourechi et

al110 average age of developing thyroid acropachy was 50 yrs. (32-82 yrs.)

106
SUMMARY

107
 SUMMARY

Present study entitled “A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT

TERTIARY CARE HOSPITAL” was carried from May 2021 to August 2022 in
department of Dermatology, Venereology and Leprology at tertiary care hospital
after approval by Scientific Review Committee and Human Research and Ethics
committee. The findings based on study are as follows:

• Total 138 Cases of Nail disorders were studied.

• Majority of cases (43%) were between the age group of 31-40 yrs. The
mean age of our study is 39 yrs.
• The youngest patient was of 20 yrs. old and oldest patient was of 72 yrs.
• Male were 56% and female were 44% with male: female of 1.26:1.
• Fingernails (54.3%) are more commonly affected then toe nails (18.1%).
• 64% cases were belonging to lower socioeconomic status class.
• 34% cases had onychomycosis with Distal & Lateral subungual
onychomycosis was predominant type and Proximal subungual
onychomycosis had least no. of cases.
• Nail psoriasis was present in 15% cases and pitting was the most common
psoriatic change among the cases.
• Paronychia was present in 8.6% cases.
• Nail lichen planus was present in 7.3% cases and out of which 30% had
pterygium formation.
• Trachyonychia was present in 3.7% cases. Majority of cases associated with
eczema.

108
• Nail changes associated with alopecia areata was present in 3% cases.
• Pitting was present in 17.4% cases. Commonest cause was psoriasis
vulgaris with nail involvement.
• Onycholysis was present in 7.24% cases.
• Beau’s lines were present in 3.87% cases.
• Muercke’s line were present in 1.44% cases
• Genodermatoses were present in 3% cases.
• 0.7% case each of acropustulosis and thyroid acropachy was reported in
present study.

109
CONCLUSION

110
 CONCLUSION

Nail changes are more common in middle age persons and seen slightly more in
male.
Involvement of less than five nail among all nails is common and fingernail
involvement is more common.
Person with lower socioeconomic class and laborer and doing house hold chores
are at risk of developing nail changes due to infections like onychomycosis and
paronychia.
Cutaneous association is most common along with nail changes. Dermatophytosis
is commonest cause involving nail and skin both followed by non-infective
conditions like psoriasis, lichen planus and eczema.
Diabetes is commonest systemic association followed by anaemia. They act as a
comorbid condition to develop variety of nail changes. Paronychia is commonly
associated with diabetes.
Onychomycosis is commonest cause of nail change with DLSO is predominant
type. Other causes of nail changes are psoriasis, lichen planus, paronychia,
eczema and alopecia areata. Nail changes due to pustular psoriasis and
pemphigus vulgaris are even though uncommon but disturbing.
Most common nail changes are pitting, onycholysis, trachyonychia etc can be

seen in different condition.

So, nail findings with systemic and cutaneous examinations are very helpful for

diagnosing various conditions and it act as a mirror of internal conditions.

111
STRENGTHS
AND
LIMITATIONS

112
Strength of study:
1. Sample encircle the wide range of presentations.

2. We could find 4 cases of rare genodermatoses

Limitations of study:

1.Larger sample size is needed.

2.As we excluded the patients of age <18 yrs, nail changes were not noted in
children and adolescents.

113
CASE IMAGES

114
 DLSO type onychomycosis SWO type onychomycosis

TDO type onychomycosis PSO type onychomycosis

115
Nail pitting with onycholysis Twenty nail dystrophy

Onycholysis in eczema Beau’s lines

116
Pitting in alopecia areata Longitudinal melanonychia

Racquet nails Pincer Nails

117
 Clubbing
Pemphigus vulgaris with
onychomadesis

Acute paronychia

Thyroid acropachy

118
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119
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71. Barnham M, Kerby J. A profile of skin sepsis in meat handlers. J Infect 1984; 9(1): 43–50
72. Indian standard classification of education by government of India under ministry of human
resource development.
73. Gunjan K et al, Socioeconomic status scale-Modified Kuppuswamy scale for year 2022
74. Senathi Usha Rani, Haritha. T, T. Suryaprakasa Rao, R. Subba Rao. Study of nail disorders in
dermatology. International Journal of Contemporary Medical Research 2019;6(1): A1-A6.
75.Puri, Neerja &Kaur, Tejinder. (2012). A study of nail disease in various dermatosis in Punjab,
India. Our Dermatology Online. 3.164-170.

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76. Bansal Goyal N, Chavan R B, Belgaukar V A. Clinico-etioogical study of nail disorders at
tertiary care centre. Indian J Dermatol Venereol Lepro 2008; 74:226-229.
77. Gujrat National Family health survey-5 (2019-20) Fact sheet pdf by ministry of health and
family welfare.
78. Garg A, Venkatesh V, Singh M, Pathak KP, Kaushal GP, Agrawal SK. Onychomycosis in central
India: a clinicoetiologic correlation. Int J Dermatol 2004; 43: 498-502.
79. Collin,RJ melanomas in chineese among southwest Indians. Cancer; 1984:55;2899-2902.
80. Sharma S, Kaur J, Bassi RSekhon HK. Dermoscopy of nail lichen planus.J Clin Aesthet
Dermatol.2021 Jul;14(7):34-37.
81. Cambiaghi S, pisstritto G, Gelmeti C. Congenital hypertrophy of lateral nail folds of hallux in
twins. Br J Dermatol, 1997,136: 635-636
82. Baran,R, Haneke E, Haneke Richert B. Pincer nails: definition & surgical treatment. Dermatol
surg 2001 27;261-266.
83. Pirracinni BM, Fenti PA, Morrelli R,Tosti A Hallopeau’s dermatitis continua of nail apparatus:
a clinical pathological study of 20 cases. Acta Derm Venereol,1994;74:65-67
84. Schlesinger N,Katz M, ingber A. Nail involvement in pemphigus vulgaris. Br J Dermatol
2002; 146:836-839.
85. Grover S. Clinico mycological evaluation of onychomycosis at Banglore and Jorhat. Indian J
Dermatol Venerol Leprol,2003;69:284-286.
86. Shenoy MM, Teerthnath S, Karnakar VK, Girisha BS. Comparison of potassium hydroxide
mount and mycological culture with histopathological examination using PAS staining of nail
clipping in diagnosis of onychomycosis. Indian J Dermatol venereal, Leprol 2008:74:226-229.
87. Blake N, Zhu J, Hernandez G, Juliano PJ. A Retrospective Review of diagnostic testing of
onychomycosis of foot.J Am Podiatr Med Asso.2015;Nov;105(6):503-508.
88. Ghosal A, Gangopadhyay DM, Chanda M, Das NK. Study of nail changes in psoriasis. Indian J
Dermatol 2004; 49: 18-21.
89. Kaur, Saraswat A; Kumar B. Nail changes in Psoriasis: a study of 167 patients. Int J Dermatol
2001;40: 601-3.
90. Tosti A, Buwrra L, Mozelli R. Role of food in the pathogenesis paronychia. J Adm Dermatol
1992; 27: 706-10.
91. Morten RH. Chronic paronychia: mycological and bacteriological study. Br J Dermatol 1959;
71: 442-6
92. Esteves J. Chronic paronychia. Dermatologica. 1959

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93. Yesudian P. D, Nwabudike, L.C and de berker, D (2022), Nail changes in diabetes. Clin
experiment Dermatol,47:9-15.
94. Nakamura R, Broce AA, Palencia DP, Ortiz NI, Leverone A. Dermatoscopy of Nail Lichen
planus. Int J Dermatol 2013;52: 684-687.
95. Francesco Ronchese, Providence RI. Nai1 in lichen planus. Arch Dermatol 1965; 9l: 347-350
96. Gandhi V, Baruah M C, Bhattacharaya S N. Nail changes in alopecia areata: Incidence and
pattern. Indian J Dermatol Venereol Leprol 2003; 69:114-5.
97. Zaias N, Escovar SX, Zaiac MN. Finger and Toenail onycholysis. J Eur Acad Dermatol
Venerol.2015;29:848-853.
98. Tosti A, Bardazzi F, Piraccini BM,FantiPA.Idiopathic trachyonychia(twenty nail dystrophy):A
pathological study of 23 patients. Br J Dermatol. 1994;131(6):866-872.
99. Baran R &Dawber RPR: Physical signs in: Baran R& Dawber eds. Disease of nails &their
management 2nd edition oxfoed Blackwell science 1994; 35-80
100. Sarojini PA, Gopalkrishan TV, Basheer AM Khaleel S. Pachyonychia congenita with
abnormalities of nails. Indian J Dermatol Venereol Leprol 1977; 43;168-169
101 Sivasundaram A, Rajagopalan K, Sarojini T. Pachyonychia congenita. Int J Dermatol,1985:
24;174-180.
102. Zaias N, Ackerman AB, the nail in darier-white disease. Arch Dermatol 1973,107:193-199.
103. Pathania V. Median canaliform dystrophy of heller occurring on thumb and great toe nails.
Med J Armed Forces india.2016:72:178-179.
104. Trovato L;Calvo,M; de Pasquale,R;scalia G;Oliveri S. prevalence of onychomycosis in
diabetic patients.J . Fungi 2022, 8,922.
105. Vidyasagar P and Kumar B (2021). Toenails changes in diabetes mellitus.IP journal of
clinical and experimental dermatology. 7.40-46.
106. Gilchrist AK Common foot problem in elderly; Geriatrics 1979;34:67-70.
107. Saraswat N, Sood A, verma R, kumar D, kumar S. nail changes induced by
chemotherapeutic agents. Indian J Dermatol 2020; 65:193-198.
108. Bergaron JR, Stone OJ, Koilonychia, A report of familial spoon nails. Arch
Dermatol,1967;95:351
109. Singh G. nails in systemic disease. Indian J Dermatol venerol leprol 2011; 77:646-651.
110. Fetourechi, Ahmed, Schwartz, J Clin Endocrinol Metab, December 2002, 87(12): 5435-
5441.

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ANNEXURES

127
 PROFORMA
PARTICIPANTS SERIAL No. DATE:
AGE:
SEX: M∕F ADDRESS:
FAMILY INCOME:
FAMILY MEMBERS:
EDUCATION: OCCUPATION:
CHIEF COMPLAINTS: DISCOLORATION/DISFIGUREMENT/PAIN/OTHER
ORIGIN
EVOLUTION:
PROGRESS:
a) Duration:
b) Site of involvement:
c) No. of nails involved:
d)Associated symptoms:
HISTORY OF TREATMENT: YES/NO
FOR NAIL CHANGES YES/NO OR FOR OTHER CONDITIONS
IF YES, WHEN &WHERE
ORAL /TOPICAL
SOME IMPROVED/WORSEN/NO CHANGE
PAST HISTORY: DM/HTN/COPD/Asthma/TB/other
FAMILY HISTORY:
PERSONAL HISTORY: ADDICTION OF TOBACCO CHEWING/SMOKING/ALCOHOL
INTAKE/OTHER

128
GENERAL EXAMINATION:
Weight: kg height: cm Clubbing:
Pallor: Cyanosis: Icterus:
Edema: Lymphadenopathy
VITALS
1. Temperature;
2. Pulse
3. Respiratory rate
4. Blood pressure

SYSTEMIC EXAMINATION:
a) Gastrointestinal system:
b) Respiratory system
c)Central nervous system:
d) Cardiovascular system

LOCAL EXAMINATION
Nail plate : COLOR - Blue/white/yellow/red/Black
SURFACE- pitting/ dystrophy/Nail splitting
SHAPE - Clubbing/koilonychia
PATTERN- longitudinal ridging/transverse ridging
Periungual tissue: Paronychia
Nail bed: Onycholysis/Hyperkeratosis
Nail matrix: Pterygium
Subungual tissue: subungual hyperkeratosis
Cuticle:

129
 Lunula:
Hyponychium:
Proximal Nail fold: Erythema / edema/ pus
Lateral Nail fold:
Skin
Hair
Mucosa

INVESTIGATION:
CBC with ESR
RBS
BIOPSY
KOH Mount
Tzanck smear:
&Any other investigation if needed.
CLINICAL DIAGNOSIS:

130
 Government Medical College, Surat
Dissertation/Thesis/Research Protocol Format

Please fill all the fields, and DO NOT LEAVE IT BLANK or DO NOT DELETE.

If not relevant, please write NOT APPLICABLE.

1.Full Title of Study: A CROSS-SECTIONAL STUDY OF NAIL DISORDERS AT TERTIARY CARE HOSPITAL

2.Goal & Objectives: a) To identify the socio-demographic distribution of different nail

disorder.

b) To identify the clinical spectrums of nail disorders.

c) To assess co-relation between nail changes with skin diseases.

3.Why this study is required? 1)Nails are not only an important aspect of the external appearance, they
are also mirrors of the internal constitution.

Please provide brief

justification with brief Review 2)The nail apparatus consists of the nail plate, and four specialized
of Literature along with epithelia: the proximal nail fold, the nail matrix, the nail bed, and the
referencing in text hyponychium. The bulk of the nail plate is constituted by hard keratins
which comprise 80% to 90% of the nail plate. The overall sulphur content
is approximately 10% by weight. The disulfide bonds of cystine in the
matrix proteins contribute maximally to nail hardness by gluing the
keratin fibers together. The lipid content is relatively low compared with
the lipid content of the stratum corneum. Glycolic and stearic acids are
main nail plate lipids.

131
3)Pathology in any portion of the nail apparatus results in an abnormal
nail sign. Nail signs occur in the nail plate, the nail bed, nail fold, and the
visible portion of the lunula

4)Nail disorders comprise of around 10% of all dermatological conditions.

Nail changes are seen in various dermatosis like psoriasis, lichen planus,
onychomycosis, collagen vascular disorders, vesiculobullous disorders
and other papulosquamous disorders.

Consequently, no dermatologic examination is complete without a

detailed examination of the nails. However, the nail still remains an
understudied, underutilized, yet quite an accessible structure that lends
itself for examination and evaluation.

The paucity of such studies has led to research for benefits and early
diagnosis and treatment for patients.

1)Singh G, Haneef NS, Uday A: Nail changes and disorders among the
elderly. Indian J Dermatol Venereol Leprol 2005; 71: 386–392.

2)Jadhav VM, Mahajan PM, Mhaske CB. Nail pitting and onycholysis. Indian
J Dermatol Venereol Leprol 2009; 75:631-3

132
4.Methodology:
Patients coming to dermatology OPD with
nail disorder

Informed written consent from patients

Time taking
is 15 mins.
↓

Detailed history will be taken using pre-printed

proforma, examination & necessary investigation
if required

Different clinical presentations like

paronychia, onychomycosis, pitting, clubbing,
koilonychia etc. as outcome parameter to be
studied.

All cases will be numbered serially,

photographed whenever necessary.
(participant’s identification number will not be
disclosed)

5.Study Design: A CROSS SECTIONAL STUDY

133
6.Sample Size with calculation: 138 with 10% frequency,95% confidence interval

7.Sampling Technique & Site: Convenient Purposive Sampling

8.Total Study Period: ONE and HALF YEAR

(Data Collection period +
Analysis and Writing)
9.Data Collection period: ONE YEAR

10.
Participant recruitment site: Skin OPD, NCH Surat

11.
Sampling technique: Convenient and purposive

12.
Inclusion criteria: a) Patients above the age of 18 yr.
b) Patients giving valid consent.

13.
Exclusion criteria a) Patients less than 18 yrs. of age.
b) Patients not giving valid consent.

c) Patients taking any medications for nail disorders.

14.
Control(s): NONE

15.
Outcome parameters, primary 1. Primary parameters like age, sex, socio-economic status etc. will be
and secondary: collected.
2. Descriptive statistics like proportion, percentage and ratio will be
calculated for above variables.

16.
Assessment tools/ scales: Detailed history of patient will be taken using pre-printed proforma, KOH
mount and nail biopsy if required. All data will be entered using MS excel
software and analysis will be done using MS excel and SPSS software

134
17.
Permission to use copyrighted NONE
tools/ questionnaire/scales

18.
Intervention if any (Dosages of NONE
drug, Duration of treatment,
Operative procedure etc)

19.
Investigations specifically Hb estimation
related to research protocol
TLC count
RBS estimation
KOH mount
Biopsy examination if needed.
20.
Follow up plan: NONE

21.
Statistical Analysis Plan: Analysis will be done by using SPSS software.

22.
Dissemination Plan: NONE

23.

135
 PARTICIPANT INFORMATION SHEET

1) TITLE: “A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT TERTIARY CARE

HOSPITAL”: Hospital based cross sectional study.

2) The study is done to determine clinical spectrum of Nail disorders.

3) Brief introduction: You will be examined for Nail disorder.

4) Method:
(a) A cross-sectional study will be done in the tertiary care hospital.
(b) History will be recorded after valid informed written consent taken from
participants in their vernacular language that they understand, and the appropriate
“Participant Information Sheet” and “Participant Informed Consent Form” will be
duly filled up by you.
(c)Participants will be evaluated in terms of age, sex, occupation, socio-economic
status and various details regarding the signs & symptoms of nail disorders.
(d) If required to aid diagnosis investigations will be done like KOH examination,
TLC count, RBS estimation, Hb estimation etc. and other relevant investigations.

5) Expected duration of the subject participation: 15 minutes

6) Participant will get correct diagnosis of the diseases or conditions. So, better
treatment will be offered to the participant.

7) There would not be any risk or discomfort to you due to study.

8) You will not incur any costs.

9) Your record will be kept confidential by giving you a unique code. No one will
be able to access your data. The concerned authorities of tertiary care hospital
and the Department of Skin & VD are permitted to use your data for research
and academic purpose.

10) You have the freedom to withdraw from research at any time without any

136
 penalty or loss of benefits to which the you would be otherwise be entitled.

11) Investigator: Dr. ANSHUL

Contact No. : 8053070520
12) I certify that the translation to the subject to vernacular is accurate.

DATE:
PLACE:
SIGN :

137
 સહભાગી માહહતી પત્રક

ુ ત વયના લોકોમાાં નેઇલ હિસોિસસનો ક્રોસ

• શીર્ષક: "ઉચ્ચસ્તરીય હોસ્સ્પટલમાાં પખ્
સેક્શનલ અભ્યાસ
• પદ્ધતિ :
(એ) ઉચ્ચ સ્િરીય હોસ્સ્પટલમાાં અભ્યાસ કરવામાાં આવશે
(બી) પ્ાાંિની માન્ય લેખિિ સાંમતિ િરીકે િેમની સ્થાતનક ભાર્ામાાં ઇતિહાસ
નોંધવામાાં આવશે અને યોગ્ય "સહભાગી માહહિી પત્ર" અને "સહભાગી માહહિગાર
સાંમતિ ફોમષ" િમે યોગ્ય રીિે ભરી શકશો.
(સી) સહભાગી ઓન ાં મ ૂલયાાંકન ઉંમર, ખલિંગ, વ્યવસાય, સામાજિક-આતથિક
પહરસ્સ્થતિઓ અને ખચહ્નો અને ખચહ્નો તવશે તવતવધ તવગિોના સાંદભષમાાં કરવામાાં
આવશે.
(ડી) િો તનદાન પરીક્ષણોને સહાય કરવાની િરૂર હોય, િો KOH ટેસ્ટ, ટીએલસી
ગણિરી, આરબીએસનો ગણિરી, એચબી ગણિરી વગેરે અને અન્ય સાંબતાં ધિ
અવશેર્ો કરવામાાં આવશે.

• તવર્ય ભાગીદારીનો અપેખક્ષિ સમયગાળો: 15 તમતનટ

• સહભાગી ને રોગો ન ાં યોગ્ય તનદાન થશે.

• અભ્યાસને કારણે િમને કોઈ િોિમ કે અસતવધા નહીં થાય.

• િમારે કોઈ િચષ કરવાની િરૂર નહીં પડે.

• અનન્ય કોડ આપી ને િમારો રે કોડષ ગપ્િ રાિવામાાં આવશે. કોઈ પણ િમારો
ડેટા વપરાશ કરી શકશે નહીં. ઉચ્ચ સ્િરીય હોસ્સ્પટલ અને ત્વચા અને
વીડી તવભાગના સાંબતાં ધિ અતધકારીઓને સાંશોધન અને શૈક્ષખણક હેત માટે
િમારા ડેટાનો ઉપયોગ કરવાની માંજૂરી આપવામાાં આવીછે .

138
 • િમને કોઈ પણ સમયે સાંશોધનમાાંથી પીછે હઠ કરવાની સ્વિાંત્રિા છે , જેમાાં
િમે હકદાર છો િેવા કોઈ પણ દાં ડ કે નફાની િોટ તવના.

• િપાસકિાષ: ડૉ. અંશલ

સાંપકષ નાંબર: 8053070520
• હ ાં પ્માખણિ કરાં છાં કે અનવાદ સ્થાતનક ભાર્ા તવશે સચોટ છે .
િારીિ:

સ્થાન:
હસ્િાક્ષર:

139
 प्रतिभागी सूचना पत्र

• परियोजना: "तृतीयक दे खभाल अस्पताल में वयस्कों में नाखून ववकारकों का

एक क्रॉस अनुभागीय अध्ययन": अस्पिाल आधारिि क्रॉस सेक्शनल
अध्ययन।

• यह अध्ययन नाखन
ू विकािों के नैदातनक स्पेक्रम का तनधाािण किने के ललए
ककया जािा है ।

• संक्षिप्ि परिचय: आपके नाखून विकािों के ललए जांच की जाएगी।

• विधध:
(क) िि
ृ ीयक दे खभाल अस्पिाल में क्रॉस-सेक्शनल अध्ययन ककया जाएगा।
(ख) इतिहास को उनकी स्थानीय भाषा में प्रतिभातिय ों से ली गई िैध सूधचि
ललखखि सहमति के बाद से दजा ककया जाएगा, औि उपयुक्ि "प्रतिभागी सूचना पत्र"
औि "प्रतिभागी सूधचि सहमति फामा" आपके द्िािा विधधिि रूप से भिा जाएगा ।
(ग) प्रतिभाधगयों का मूलयांकन उम्र, ललंग, व्यिसाय, सामातिक-आतथिक स्थथति
औि संकेिों औि लिणों के बािे में विलभन्न विििणों के संदभा में ककया जाएगा।
(घ) यदद तनदान जांचों में सहायिा किने की आिश्यकिा है िो KOH
पिीिा,टीएलसी काउं ट, आिबीएस अनुमान, एचबी अनुमान आदद औि अन्य
प्रासंधगकअिशेषों की ििह ककया जाएगा ।,

• भािीदार की भागीदािी की अपेक्षिि अिधध: 15 लमनट

• भािीदार को बीमारियों या स्स्थतियों का सही तनदान लमलेगा।

• अध्ययन के कािण आपको कोई जोखखम या असुविधा नहीं होगी।

140
 आपको कोई लागि नहीं उठानी होगी।

• एक यूतनक कोड दे कि आपका रिकॉडा गोपनीय िखा जाएगा। कोई भी

आपके डेटा िक पहुंचने में सिम नहीं होगा। िि
ृ ीयक दे खभाल अस्पिाल
औि त्िचा औि िीडी विभाग के संबंधधि अधधकारियों को अनुसंधान औि
अकादलमक उद्दे श्य केललए आपके डेटा का उपयोग किने की अनुमति है ।

• आप ककसी भी दं ड या लाभ की हातन है जो आप अंयथा हकदाि हो

जाएगा बबना ककसी भी समय अनुसंधान से िापस लेने की स्ििंत्रिा है ।

• अन्िेषक: डॉ अंशुल
संपका संख्या: 8053070520
• मैं प्रमाखणि कििा हूं कक स्थानीय भाषा के विषय में अनुिाद सटीक है ।

ददनांक:
जगह:

141
 PARTICIPANT INFORMED CONSENT FORM (PICF)

Participant serial number for this trial: _______________________

Title of project: A CROSS SECTIONAL STUDY OF NAIL DISORDERS AT TERTIARY
CARE HOSPITAL.

The contents of the information sheet dated ……………….. that was provided to me,
have been carefully read by me / explained in detail to me, in a language that I
comprehend, and I have fully understood the contents. I confirm that I have had
the opportunity to ask questions.

The nature and purpose of the study and its potential risks / benefits and expected
duration of the study, and other relevant details of the study have been explained
to me in detail. I understand that my participation is voluntary and that I am free
to withdraw at any time, without giving any reason, without my medical care or
legal right being affected.

I understand that the information collected about my nails and my participation in

this research and sections of any of my medical notes and clinical photographs may
be looked at by responsible individuals from Department of skin and venerology
and leprology, New Civil Hospital and Government Medical College, Surat. I give
permission for these individuals to have access to my records.

I agree to take part in the above study.

---------------------------------------------
(Signatures / Left Thumb Impression)

Name of the Participant: ____________________________________

Complete postal address: _____________________________________

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This is to certify that the above consent has been obtained in my presence.
Sign of witness: ________________________________
Name of witness: _______________________________

------------------------------
Signatures of the Principal Investigator
Principal Investigator: Dr. Anshul
Mobile No.8053070520

Date:
Place:

143
 સાંપ ૂણષ જાણકારી સાથે ન ાં સાંમતિ પત્રક:

અભ્યાસમાાં ભાગ લેનારનો ઓળિ નાંબર:_____________________________

અભ્યાસન ાંુ શશર્સક: ઉચ્ચ સ્િરીય હોસ્સ્પટલમાાં નિના રોગો પર અભ્યાસ.

િારીિ ____________ ના હદને માહહિી પત્રકમાાંની િમામ તવગિો મને, હ ાં સમજી

શકાં એ ભાર્ામાાં સમજાવવામાાં આવી છે / મેં વાાંચી છે . અને હ ાં એ િમામ વાિો સમજી
ચ ૂક્યો છાં. અને હ ાં બાાંહધ
ે રી આપ ાં છાં કે આ દરમ્યાન મને સવાલો પ ૂછવાનો મોકો મળ્યો
છે .

આ અભ્યાસનો પ્કાર અને એનો હેત િથા સાંભતવિ ફાયદા-ગેરફાયદા અને અંદાજિિ
સમય િથા અન્ય જાણકારી મને તવગિવાર સમિવામાાં આવેલ છે . હ ાં એ સમજી શકાં
છાં કે હ ાં આ અભ્યાસમાાં સ્વૈચ્ચ્છક રીિે ભાગ લઇ રહયો છાં િથા ગમે ત્યારે જાણ કયાષ
તવના કે મારા સ્વાસ્્ય કે કાયદાકીય અતધકાર ને હાતન પહોંચ્યા તવના આ અભ્યાસ
માાંથી મકિ થઇ શકાં છાં.

હ ાં સમજ છાં કે આ અભ્યાસમાાં મારા સહયોગથી મારા નિ તવશે એકતત્રિ કરવામા

આવેલી તવગિો અને મારા નિ તવર્ેની િબીબી નોંધો િેમિ નિ પરના
ડાઘ/લક્ષણોનો ફોટો સરકારી િબીબીમહાતવધ્યાલય, નવી તસતવલ હોસ્સ્પટલ, સરિના
ચામડી અને ગપ્િ રોગ તવભાગના િવાબદાર વ્યસ્કિઓ દ્વારા િોવા મા આવશે. હ ાં
મારા રે કોડષ ના વપરાશ માટે આ વ્યસ્કિઓને પરવાનગી આપ ાં છે .

144
આ સાથે હ ાં અભ્યાસમાાં ભાગ લેવાની પરવાનગી આપ ાં છાં.

સહભાગીની સહી/ડાબાઅંગ ૂઠાનીછાપ

િારીિ:__________

સહભાગીન ાં નામ: સ્થળ: સરિ

પોસ્ટલ સરનામ:

ટેખલફોન નાંબર:

હ ાં પ્માખણિ કરાં છાં કે ઉપરોકિ માહહિી મારી હાિરીમાાં લેવામાાં આવી છે .

મખ્ય િપાસકિાષના હસ્િાક્ષર:

િારીિ:_____________

સાક્ષીના હસ્િાક્ષર: સ્થળ: સરિ

નામ:

સરનામ:ાં

મખ્ય િપાસકિાષન ાં નામ : ડૉ. અંશલ

મખ્ય િપાસકિાષનો ટેખલફોન નાંબર: 8053070520

145
 िोगी का जानकािीपूणा सहमति पत्रक

अभ्यास हे िु िोगी का पहचान क्रमांक: ____________________

इस अभ्यास का शीषाक: अस्पिाल में नाखून िोगों पि क्रॉस सेक्शनल अध्ययन

जानकािीपत्र में दी गयी सभी चीज़ों के बािे में ददनांक___________को मुझे

अपनी भाषा में समझाया गया है मैंने ध्यान से पढ़ा है औि मैंने सभी चीज़ों को
अच्छी ििह से समझ ललया है । मुझे सिाल पछ
ू ने का पूिा मौका ददया गया है ।

इस अभ्यास की प्रकृति औि उद्दे श औि संभाविि लाभ/जोखखम औि संभाविि

समय, औि अभ्यास की पूिी जानकािी विस्िाि से समझाई गयी है । मैं यह
जानिा/जानिी हूूँ की मैं अपनी इच्छा से इस अभ्यास में भाग ले िहा/िही हूूँ औि
मैं कभी भी कोई भी िजह बिाये बबना अपना नाम िापस लें सकिा/सकिी हूूँ

औि मुझे बिाया गया है कक इसका मेिे इलाज पे या दस

ु िे ककसी भी अधधकाि पे
कोई असि नहीं पड़ेगा।

मैं यह जानिा/जानिी हूूँ कक यह अभ्यास द्िािा जो जानकािी इकठ्ठा होगी िो

औि अन्य कोई िैद की जानकािी का इस्िेमाल _______विभाग, नया लसविल
हास्स्पटल, सूिि के डाक्टि इसकी जांच-पड़िाल कि सकिे हैं औि मैं इन लोगों को
मेिी पहचान गोपनीय िखने की शिा पि इस्िेमाल किने की सहमति दे िा/दे िी हूूँ।

मैं अभ्यास में सहभागी होने की सहमति दे िा/दे िीहूूँ।

146
________________________

(हस्िािि/उलटे अंगूठे की छाप)

िोगी का नाम _______________________

पूिा पिा___________________________

मैं यह प्रमाखणि कििा/कििी हूूँ की ऊपि दी गयी सहमति मेिे सामने ली गयी
है ।

गिाह के हस्िािि_____________

गिाह का
नाम_________________________________________________

मुख्यि पासकिाा के हस्िािि:___________________

मख्
ु यि पासकिाा:

टे लीफोन नंबि :

ददनांक_________

जगह__

147
KEY TO MASTERCHART:

SEX:
M- MALE
F- FEMALE
Nail involved
F1: Left little finger
F2: left ring finger T10: Right little Toe
F3: left middle finger
F4: left index finger
F5: left thumb
F6: Right thumb
F7: Right index finger
F8: Right middle finger
F9: Right ring finger
F10: Right little finger
T1: left little Toe
T2: Left 4th Toe
T3: left 3rd Toe
T4: Left 2nd Toe
T5: Left great toe
T6: Right great toe
T7: Right 2nd Toe
T8: Right 3rd Toe
T9: Right 4th Toe

148
149
________

150