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Nail abnormalities

Specialties > Dermatology

Differential Diagnosis Schema 🧠

Nail Discoloration

  • Terry’s Nails: White nails with a distal pink or brown band; associated with liver disease, heart failure, and diabetes.
  • Beau’s Lines: Transverse grooves in the nails; often indicate a temporary disruption in nail growth due to systemic illness, trauma, or chemotherapy.
  • Melanonychia: Brown or black discoloration of the nail; may be due to benign causes like melanocytic activation or more serious conditions like melanoma.
  • Leukonychia: White spots or lines on the nails; can be due to trauma, zinc deficiency, or hypoalbuminemia.
  • Yellow Nail Syndrome: Yellow discoloration, thickening, and slow growth of the nails; associated with lymphedema and respiratory disorders.

Nail Shape Abnormalities

  • Clubbing: Bulbous enlargement of the distal phalanges with increased nail curvature; associated with chronic hypoxia (e.g., lung disease), congenital heart disease, and gastrointestinal disorders.
  • Koilonychia (Spoon Nails): Concave, spoon-shaped nails; often due to iron-deficiency anemia, hemochromatosis, or hypothyroidism.
  • Onycholysis: Separation of the nail from the nail bed; can be associated with trauma, psoriasis, hyperthyroidism, or fungal infections.
  • Pincer Nails: Increased transverse curvature of the nail; may be congenital or associated with systemic conditions like psoriasis or lupus.
  • Habit-Tic Deformity: Central depression of the nail with parallel transverse grooves; usually due to repetitive trauma or habitual picking.

Nail Texture and Thickness Abnormalities

  • Onychomycosis: Fungal infection leading to thickened, brittle, and discolored nails; more common in the elderly and immunocompromised.
  • Psoriatic Nails: Pitting, onycholysis, and subungual hyperkeratosis; seen in patients with psoriasis, often alongside skin and joint involvement.
  • Trachyonychia (Twenty-Nail Dystrophy): Rough, sandpaper-like texture of all nails; associated with lichen planus, alopecia areata, or eczema.
  • Onychogryphosis: Hypertrophy and curvature of the nail, often resembling a ram’s horn; seen in elderly patients or those with neglected nails.
  • Brittle Nails: Can be due to repeated wetting and drying, hypothyroidism, or nutritional deficiencies such as biotin or iron deficiency.

Key Points in History 🥼

Symptomatology

  • Onset and Duration: Determine when the nail abnormality was first noticed and whether it has changed over time.
  • Associated Symptoms: Ask about associated symptoms such as pain, discoloration, itching, or signs of infection.
  • Systemic Symptoms: Inquire about any systemic symptoms such as fatigue, weight loss, or respiratory symptoms that may point to an underlying systemic condition.
  • Pattern of Involvement: Whether the abnormality is affecting one nail, several nails, or all nails, which can help narrow down the differential diagnosis.
  • Precipitating Factors: Any history of trauma, new medications, or recent illness that could have triggered the nail changes.

Background

  • Past Medical History: Important to note any history of systemic diseases like diabetes, cardiovascular disease, or thyroid disorders.
  • Drug History: Review any medications, especially those known to cause nail changes, such as chemotherapeutic agents, retinoids, or tetracyclines.
  • Family History: Inquire about family history of nail abnormalities, psoriasis, or connective tissue disorders, which may suggest a hereditary pattern.
  • Social History: Assess lifestyle factors such as occupation, exposure to chemicals, smoking, and nail care habits that might contribute to nail abnormalities.
  • Travel History: Consider any recent travel that might expose the patient to endemic infections, such as fungal infections.

Possible Investigations 🌡️

Laboratory Tests

  • Nail Clipping for Mycology: Microscopy and culture for fungal infections if onychomycosis is suspected.
  • Blood Tests: Consider a full blood count, renal function, liver function tests, and thyroid function tests depending on the suspected underlying condition.
  • Serum Ferritin and Iron Studies: Assess for iron deficiency anemia, particularly if koilonychia is present.
  • Autoantibody Screen: Consider ANA and RF if autoimmune conditions such as lupus or rheumatoid arthritis are suspected.
  • Biopsy: In cases where malignancy (e.g., subungual melanoma) is suspected, a biopsy of the nail bed or matrix may be indicated.

Imaging and Specialist Tests

  • X-ray: May be useful in cases of suspected bone involvement or trauma affecting the nails.
  • Dermatoscopy: Non-invasive imaging technique that can help in diagnosing nail pigmentation issues, such as melanonychia or subungual melanoma.
  • Patch Testing: Consider if contact dermatitis is suspected to be causing nail abnormalities.
  • Referral to Dermatology: Consider for complex cases or when there is suspicion of malignancy, severe psoriasis, or other systemic conditions requiring specialist input.

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Dermatology