Updated: 1/26/2018

Nail Disorders

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Snapshot
  • An 8-year-old girl presents to her pediatrician 2 days after accidentally slamming a door on her index finger. She reports significant throbbing pain after the incident. On physical exam, her right index finger is swollen with a blue-black discoloration under the distal nail. A radiograph reveals no fracture. The physician explains that as the blood has clotted, there is no point in draining the subungual hematoma. (Subungual hematoma)
Introduction
  • Nail unit is composed of
    • nail bed
    • paronychium (proximal and lateral nail fold)
    • eponychium (cuticle)
    • lunula
  • Growth is approximately 1 mm per month
Subungual Hematoma
  • Clinical definition
    • blood clot under the nail
  • Etiology
    • trauma
  • Presentation
    • blue-black hematoma under the nail plate
    • throbbing pain
  • Treatment
    • trephination
      • indication
        • if the subungual hematoma occurred within 48 hours and has not clotted
    • non-steroidal anti-inflammatory drugs (NSAIDs)
      • indication
        • for all patients
Splinter Hemorrhages
  • Clinical definition
    • ruptured nail bed capillaries characterized by narrow lines under the nails
  • Etiology
    • trauma
      • typically associated with the distal nail plate
    • systemic diseases
      • typically associated with the proximal nail plate
  • Associated conditions
    • psoriasis
    • infective endocarditis
    • lichen planus
    • other chronic dermatoses
  • Presentation
    • red or black longitudinal lines under the nail plate
Koilonychia
  • Clinical definition
    • upward curving of the distal nail plate
    • also called spoon nail
  • Associated conditions
    • iron deficiency
  • Presentation
    • spoon-shaped upward curving of the distal nail plate
Leukonychia
  • Clinical definition
    • white discoloration from the defective keratinization of the distal matrix
    • subtype of leukonychia is Mees lines
      • transverse white striae that run parallel to the nail base
  • Etiology
    • trauma
    • infection
    • drugs
    • arsenic or lead poisoning
  • Demographics
    • children
  • Presentation
    • white discoloration of the nail in patches or striae
Beau Lines
  • Clinical definition
    • temporary arrest of the nail matrix proliferation
  • Etiology
    • trauma
    • drugs (retinoids)
    • infection
  • Presentation
    • transverse grooves that move with nail growth
Pitting
  • Clinical definition
    • pitting from the abnormal keratinization of the nail matrix
  • Associated conditions
    • psoriasis
    • alopecia areata
  • Presentation
    • “ice pick-like” depressions in the nail
Onycholysis
  • Clinical definition
    • separation of the nail from the nailbed
  • Etiology
    • trauma
    • drugs
  • Associated conditions
    • Graves’ disease
    • psoriasis
    • squamous cell carcinoma
  • Presentation
    • white discoloration of the nail plate
      • discoloration is due to air underneath
  • Complication
    • higher risk of dermatophyte nail infections
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