CASE CONFERENCE:Nail Disorders

KAREN ESTRELLA05/12/2010

Do you check the nails of your patients?

History

3y/o M seen at SBC for 1st WCC-no acute concerns except for: changes in nail bed of left 2nd nail for 1 year

Normal nail

• EMBRIOLOGY: – starts to develop at 10-11 wks– keratinizes from 15 wk– fully formed by birth

Normal nail• ANATOMY:

Consult DERMATOLOGY:

• Dark linear, uniform, well demarcated linear ban along the nail bed, involving proximal nail fold

Melanonichia striata

What is melanonychia?

• Tan, brown or black pigmentation from the proximal nail fold and cuticle to the free distal end of the nail plate– Usually affects 1 or 2 digits

• Due to: melanocyte activation (physiologic), benign melanocyte hyperplasia (nevi), or melanoma.

• Most common in african-american or hispanics

Melanonychia etiology: benign• LOCAL

– Trauma– Radiation– Nail bitting– Foreign body– Infection

Single bands

• SYSTEMIC– Addison, Cushing,

Hyperthyroidism, – Hemosiderosis– Alcaptonuria– Psoriasis– LES, scleroderma– Malnutrition

Multiple bands

Melanonychia etiology: iatrogenic

• CHEMOTHERAPY– Metotrexatem– Bleomycin– Doxorubicin– Ciclophosphamide– 5-fluoruracil

• OTHERS– Steroids, – Ibuprofen– Phenytoin– Zidovudine, lamivudine– Ketokonazole,

fluconazole

Melanonychia etiology: malignancy

• Age: adults• Brown-black band greater than 3 mm• Change in nail band morphology despite treatment • Digit involved: The thumb is more likely to be affected

by subungual melanoma than the great toe; the great toe is more likely than the index finger to be affected by subungual melanoma.

• Extension onto the adjacent cuticle and proximal and/or lateral nail folds (Hutchinson sign)

• Family or personal history of dysplastic nevus or melanoma

Melanonychia work-up• Dermatoscopic evaluation:– Of the free edge of nail bed

Melanonychia: Dermatoscopic evaluation continued

Melanonychia: work-up continued

• Nail bed Sampling: – Punch bx: 3mm, from proximal matrix• Risk of permanent nail dystrophy

– Nail-shave bx : 4-6mm, central portion of nail bed– lateral-longitudinal

– If suspicion for subungueal melanoma: full thickness

Melanonychia Treatment

• Tx of underlying condition• Removal of agent• If melanoma: complete removal of

hyperpigmented section

OTHER NAIL DISORDERS

Congenital disorders:(Ectodermal defects)• ANONYCHIA

– Associated with nail-patella sd., deafness

• PACHONYCHIA– Associated with:

hyperhidrosis, leukokeratosis: TM, cornea, mucosas

Congenital disorders continued

• HYPOPLASTIC– Phenytoin– Warfarin– Fetal alcohol

syndrome

Associated with systemic disorders

• CLUBBING– hypoxic stages

• KOILONYCHIA (spoon nails)– Iron deficiency

Associated with systemic disorders• HALF & HALF NAILS– liver, kidney failure

• SPLINTER HEMORRHAGES– endocarditis

• RIDGING-TRANSVERSE LINES - malnourishment

Acquired nail disorders: infection• PARONYCHIA

– Red, tender, swelling of prox or lateral fold• Acute: S. aureus• Chronic: Candida

albincans

• ONYCHOMYCOSIS- yellowish, brittle- Unusual before

puberty- Systemic antifungal tx

Acquired nail disorders: dystrophy(distortion, discoloration)

• TRAUMA– Subungual hematoma

• PSORIASIS

Acquired nail disorders: dystrophycontinued

• TRACHYONYCHIA(Twenty nail dystrophy)– School children– Yellow or gray color

nails, (+) pitting, friable– Progresses in 6-18

months, self-limited– Some cases associated

with alopecia areata, atopic dermatitis

Thank you : )

References• Cohen, B. pediatric Dermatology. Mosby LTD, Spain: 1999. pg 201-208• www.dermaimaging.com/?cat=39• http://www.ncbi.nlm.nih.gov/pubmed/10411404• http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-

05962009000200013&lng=en&nrm=iso>. ISSN 0365-0596. doi: 10.1590/S0365-05962009000200013.

• http://emedicine.medscape.com/article/1375850-overview• http://www.medscape.com/viewarticle/718695_7