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Facts about the skin from DermNet New Zealand Trust. Topic index: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


Examination of the nails

Learning objectives
Introduction
Abnormalities of the nail plate surface
Discolouration of nails
Cuticle and nail fold abnormalities
Abnormalities of nail shape
Loss of nails
Lesions around nails
Activity

Learning objectives

Develop skills in examining the nails and describing:

Introduction

This section provides a glossary of terms used to describe abnormal fingernails and toenails. Proper use of language is necessary for diagnosis and to communicate with other health professionals.

Nails are a specialised form of stratum corneum and are made predominantly of keratin. Their primary functions are for protection, scratching and picking up small objects. When looking at the nails carefully inspect the nail plate and surrounding skin.

Normal nail
Normal nail

If the patient presents with a nail problem, it is important to ask about skin disease elsewhere and examine them generally. Fungal nail disease (onychomycosis) is nearly always associated with fungal skin disease (check feet, hands, groin). Nail changes may be the first sign of psoriasis (check scalp, elbows, knees and flexures), lichen planus (check oral mucosa, lower back, scalp, wrists and ankles) or other skin diseases.

Psoriasis may result in haphazard nail pitting, onycholysis, subungual hyperkeratosis, ridging and/ or yellow hypertrophied nail plate.

Eczema is associated with irregular pitting and ridging and paronychia.

Abnormalities of the nail plate surface

Nail plate abnormalities are often due to inflammatory conditions affecting the matrix or nail bed. Specific diagnoses may be made from characteristic appearances, which are generally self-explanatory.

Pitting
Eczema
Psoriasis
Alopecia areata
Nail pitting
Transverse ridging
Eczema
Psoriasis
Beau's line: single ridge across nail: Acute systemic illness, Trauma
Beau line
Longitudinal ridging and / or longitudinal splitting
Ageing
Trauma
Lichen planus
Darier's disease
Onychomycosis
Psoriasis
Nail ridgeNail notching
Longitudinal groove
Cyst or tumour of matrix
Trauma
Nail groove
Onychogryphosis (thick hard curved nail plate)
Ageing
Psoriasis
Trauma
Onychogryphosis
Nail plate thinning
Lichen planus
Trauma
Angelwing deformity
Nail plate crumbling
Psoriasis
Onychomycosis
Crumbling nail
Distal lamellar splitting; brittle nails
Water/detergent damage
Nail polish removers
Traumatic removal or artificial nails
Onychoschizia
Distal notching
Darier's disease
Lichen planus
Rough nails
Lichen planus
Twenty Nail Dystrophy
Trachyonychia
Erosion
SCC
Melanoma
Trauma
Nail melanoma

Discolouration of nails

Distinguish a discoloured nail bed from a discoloured nail plate.

Yellow
Yellow nail syndrome
Onychomycosis
Psoriasis
Staining from nail enamel
Onychomycosis
Onycholysis (white or yellow distally,; nail plate lifted off nail bed)
Skin diseases: psoriasis, dermatitis, lichen planus
Idiopathic
Trauma
Systemic disease
Nail infection
Tumour under distal nail plate
Drug photosensitivity
Onychomycosis
Green
Infection
Paronychia
Brown or black
Staining
Drugs
Infection
Melanocytic naevus
Melanoma
Racial
Melanocytic naevus on nail
White (leukonychia)
Vitiligo
Trauma
Hypoalbuminaemia.
Chronic renal failure.
Chemotherapy
Familial
Onychomycosis
Onychomycosis
Red
Lunula
Darier's disease
Inflammation
Terry nail
Blue
Drugs
Blue nail
Purple/black
Splinter haemorrhage
Haematoma
Splinter haemorrhage

Cuticle and nail fold abnormalities

The cuticle is an area of keratin joining the skin of the posterior nail fold to the nail plate. Loss of cuticle results in paronychia: an acute or chronic inflammatory reaction involving nail fold (swelling, tenderness, sometimes pus).

Ragged cuticles & telangiectases
Trauma: hang nail
Connective tissue disease
Nailfold telangiectases
Distal digital infarcts
Vasculitis
Vasculitis
Distal subungual hyperkeratosis
Psoriasis
Onychomycosis
Norwegian scabies
Psoriatic nail
Paronychia
Acute
Chronic
Candida paronychia

Abnormalities of nail shape

Long nail
Uncut
Long nail
Longitudinal over-curvature
Systemic sclerosis
Sarcoidosis
Curved nail
Clubbing
Chronic lung disease
Cardiac disease
Liver disease
Ulcerative colitis
Collagen vascular disease
Thyrotoxicosis
Clubbing
Koilonychia (thin spoon-shaped nail)
Infants & elderly
Local injury
Iron deficiency anaemia
Systemic retinoids
Koilonychia
Pachyonychia (wedge-shaped nails)
Pachyonychia congenita
Idiopathic
Pachyonychia
Pincer nail (transverse over-curvature)
Epidermal cyst
Idiopathic
Pincer nail
In-grown nail
Granulomas are common
Systemic retinoids
Ingrown nail

Loss of nails

Without scarring
Trauma e.g. nail biting
Bitten nail
Scarring
Trauma e.g. surgery
Tumour
Erosive lichen planus
Onychomadesis
Onychomadesis (nail shedding)
Severe systemic disease
Severe lichen planus
Lichen planus

Lesions around nails

Common skin lesions that may arise close to nails include:

Viral wart

Wart
Corn

Corn
Myxoid cyst

Myxoid cyst
Melanocytic naevus

Nail naevus
Melanoma

Nail melanoma
Squamous cell carcinoma
Pyogenic granuloma

Pyogenic granuloma

Activity

Describe the clinical signs of onychomycosis.

 

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References:

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Author: Clin Assoc Prof Amanda Oakley

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