A substantial amount of information can be gathered by analyzing an individual’s toenails and/or fingernails. From possible malignancy to nutritional status, an individual’s toenails and/or fingernails can often fill in the needed ‘blank spaces’ and provide you with a significant amount of insight into their overall health and wellness. In order to ensure that as much information as possible is gathered, it is essential that clinicians undertake a thorough evaluation of each individual’s nails at each physical examination. In order to ensure that the most accurate information is obtained, it is important that the examination is done in good lighting conditions. Careful examination can help the clinician to detect a number of general and specific pathologic indicators and ensure as much information as possible is gathered pertaining to an individual’s health, wellness and presented condition.
EXAMINATION OF THE NAIL:
When evaluating an individual’s nails, there are a variety of things to look at. Nail color is a potentially useful method for identifying systemic problems. White nails can be caused by anemia, renal failure, cirrhosis, diabetes mellitus, or chemotherapy. Pink or red nails may suggest polycythemia, SLE, carbon monoxide poisoning (cherry red), angiomas, or malnutrition. Brown-gray nails may indicate cardiovascular disease, diabetes mellitus, vitamin B12 (cobalamin) deficiency, breast cancer, melanoma, lichen planus, or syphilis. Green or black nails may be caused by trauma, chronic Pseudomonas infection, or topical preparations. Examination of the nails should also include assessment of the softness and flexibility of the free edge, the shape of the nail, the quantity of paronychial tissue, and the growth rate. The normal average growth rate is about 3 mm per month for fingernails and 1 mm per month for toenails. Nails of the dominant hand usually grow faster than nails of the non-dominant hand. Aging slows the nail growth rate by about 0.5% each year after the age of 25. Immobility is also another factor that can slow the growth rate of nails. Nails are usually thicker in the elderly than in younger people.
NAIL INFECTION DEVELOPMENT:
The primary purpose of the nail is to protect the digital tip, in addition it also contributes to tactile sensation and aids in peripheral thermoregulation. Although abnormalities of the nail are often caused by skin disease and infection, they may also indicate more general medical conditions. It is therefore important to conduct a thorough evaluation in order to collect as much information as possible pertaining to the individual. While nail infections and/or the development of a nail fungus is often considered a niche problem affecting a small group of people, it is far more common than most people think. Nail fungus infection is a common disease affecting around 12% of the population worldwide and over 50% of people over 70 years. Diseases of the nails can cause significant social, psychological, and physical damage to an affected individual. These disorders may be isolated to the nail unit itself or they may be part of a larger systemic disease that may be evident first, or only, in the nail unit. If a nail infection and/or fungus is left untreated it can also spread to other presumable healthy nails. It is therefore important to address the infection as soon as possible!
ADDRESS THE NAIL INFECTION AS SOON AS POSSIBLE
Fungal infections of the fingernails and toenails (onychomycosis) can be difficult to treat in individuals. It also has a high recurrence rate. Most treatment measures for dealing with nail fungal infections prove to be ineffective as they don’t manage to penetrate deep enough under the nail, thereby resulting in the infection returning. SFN10 however has a unique micro-bristle applicator that allows for deep and sufficient penetration under the nail. SFN10 penetrates deeper under the nail than any other applicator currently on the market.
SFN10 CONTAINS A UNIQUE MICRO-BRISTLE APPLICATOR THAT PENETRATES DEEPER UNDER THE NAIL THAN ANY OTHER APPLICATOR CURRENTLY ON THE MARKET
We will now take a closer look at some of the common fingernail and/or toenail abnormalities as well as infections that can develop:
NAIL CLUBBING:
Nail clubbing occurs when the angle made by the proximal nail fold and the nail plate, termed the Lovibond angle, is greater than 180° (the Lovibond angle of normal nails is generally <165°). Nail clubbing has been associated with various underlying pulmonary and cardiovascular disorders, as well as with neoplastic, infectious, hepatobiliary, mediastinal, endocrine, and gastrointestinal diseases. Hamman-Rich syndrome, or acute interstitial pneumonitis, is a form of idiopathic interstitial pneumonia that is characterized by inflammation of the lung interstitium. With advanced interstitial lung diseases, digital clubbing and signs of right heart failure may appear.
ABNORMALITIES OF THE LUNULA:
The lunula is the distal extent of the germinal matrix of the nail bed. Abnormalities of the lunula are common and may lead clinicians down varied diagnostic paths. A pyramidal lunula may be a sign of excessive manicure or trauma. A pale blue lunula may indicate diabetes mellitus, whereas a red discoloration of the lunula may signify cardiovascular disease, collagen vascular disease, hematologic malignancy, or another serious diagnosis. The nails shown are lacking the lunula. The lunula, the visible region of the distal nail matrix, is most noticeable on the thumb, although the eponychium may partially or completely cover the lunula. Absence of the lunula (anolunula) of the thumb should prompt investigation for anemia or malnutrition. However, this may also be a normal finding. Anolunula of other digits is nonspecific.
YELLOW NAIL SYNDROME:
Yellow nail syndrome is characterized by yellow nails that lack a cuticle, grow slowly, and are loose or detached (onycholysis). This condition is most commonly associated with lung disorders (bronchiectasis) and with lymphedema, but it can be suggestive of diabetes mellitus, amyloidosis, median/ulnar nerve injury, thermal injury, or jaundice.
KOILONYCHIA:
Koilonychia is a condition characterized by spoon-shaped, concave nails. Causes of koilonychia include iron deficiency, diabetes mellitus, protein deficiency (especially in sulfur-containing amino acids), SLE, exposure to petroleum-based solvents, trauma, and Raynaud disease.
LINDSAY HALF-AND-HALF NAILS:
The term Lindsay half-and-half nails refers to a condition in which the proximal portion (40-80%) of the nail bed is white and the distal portion is dark (red, pink, or brown). The white portion is related to edema and anemia. These nails are indicative of renal disease. In the condition known as Terry nails, the proximal 80% of the nail bed is white and the distal portion of the bed is a normal pink. Terry nails are caused by a reduced vascular supply to the nail bed.They are indicative of hepatic disease, although they can also suggest diabetes mellitus, congestive heart failure, or hyperthyroidism, or Terry nails may be related to aging.
PROXIMAL SUBUNGUAL ONYCHOMYCOSIS (PSO):
Proximal subungual onychomycosis (PSO) is a rare fungal nail infection that is associated with immunodeficiency or local trauma. The white patch initially appears under the nail fold, but it progressively migrates distally with nail growth. If PSO is caused by a mold, marked periungual inflammation is usually present.PSO requires systemic antifungal treatment when the lunula is involved; topical agents may be sufficient when only the distal nail is affected. Another condition, onycholysis involves the distal separation of the nail plate from the underlying nail bed; usually, no inflammation is involved. Onycholysis is associated with conditions such as thyrotoxicosis, psoriasis, eczema, trauma, contact dermatitis, tetracycline, toxic exposures (solvents), blistering from autoimmune disease, and porphyria cutanea tarda (onycholysis and skin blistering from sun exposure). Therapy is dependent on the etiology and includes removing the predisposing cause, keeping the nails short, and avoiding exposure to contact irritants and moisture.
Longitudinal brown lines form as a result of increased melanin production by nail matrix melanocytes.These lines are associated with Addison disease, a melanocytic nevus of the nail matrix, melanoma (check for periungual pigmentation), solar lentigo, certain medications, genetic predisposition, and trauma. Beau lines are transverse depressions in the nail plate resulting from temporary cessation of nail growth. Causes include intermittent doses of immunosuppressive therapy or chemotherapy, nail injury, cold temperatures, and illness.Severe zinc deficiency has also been proposed as a cause of Beau lines. By noting the location of a Beau line on the nail, a clinician can determine the approximate date of the illness associated with it. Moreover, the depth of the line provides a clue to the severity of the illness.
ONYCHORRHEXIS:
Onychorrhexis, or the presence of longitudinal striations or ridges on the nail plate, can simply be a sign of advanced age, but it may also be associated with conditions such as rheumatoid arthritis, peripheral vascular disease, lichen planus, and Darier disease (broad white and red striations in the nails). A central vertical ridge or groove may be due to myxoid cysts that appear near the nail fold; myxoid cysts are associated with osteoarthritis.
SPLINTER HEMORRHAGE:
Splinter hemorrhages are caused by small areas of bleeding of the distal capillary loops in the nail bed and are most commonly associated with subacute bacterial endocarditis (classic finding) and local trauma.These red or brown linear hemorrhages may also be associated with vasculitis,microemboli, trichinosis,onychomycosis,psoriasis,SLE, pityriasis rubra pilaris,or renal failure.
ACUTE ILLNESS:
Any acute illness can produce transverse white lines, also known as Mees lines. In addition, they may be caused by heavy metal toxicity (classically associated with arsenic poisoning), chemotherapy, carbon monoxide poisoning, Hodgkin disease, malaria, or leprosy. The timing of the causative event or disease process may be determined from the location of the lines on the nails.
PROXIMAL NAIL MATRIX INFLAMMATION:
Small punctate depressions of the nails, or “pitting”, is caused by proximal nail matrix inflammation.This inflammation is most commonly related to psoriasis (random appearance of pits), but it is also associated with alopecia areata (geometric, rippled grid), eczema, reactive arthritis, and lichen planus.Nail pitting may also occur without disease.
TUBEROUS SCLEROSIS:
Tuberous sclerosis complex is a genetic disorder that causes benign tumors to grow in many different organs. Ungual or periungual fibromas may appear in adolescents or adults with tuberous sclerosis. Fibromas may cause distortion of the nail or nail bed and can occur as an isolated sign of tuberous sclerosis. Generally, when these fibromas involve the toes, they may bleed and cause discomfort.
It is important to be aware of any changes that occur with regards to both the appearance and structure of your toenails and fingernails. Going for regular examinations, especially if you are at a higher risk of developing a nail infection and/or abnormality, and addressing it as soon as possible is essential to your overall health and wellbeing.