Hitting the Nail on the Head: Clues to Systemic Disease

Scott Sears, MD FACP

Internal Medicine Associates

Billings, MT

Transverse linesA) Muehrcke’s Lines

B) Beau’s Lines

C) Leukonychiapunctata

D) Mee’s Lines

Muehrcke’s Lines

Muehrcke’s LinesWhat it is:• an abnormality of the vascular nail bed

What you see:• pairs of transverse white lines that extend all the

way across the nail (parallel to lunula)• it goes away with nail pressure• it does not grow out

• What it’s associated with:• hypoalbuminemia (albumin <2)• nephrotic syndrome • malnutrition• cirrhosis

Beau’s lines

Beau’s lineWhat it is:• representation of nail growth arrest

What you see:• deep transverse grooves in the nail(s)• can be single or multiple• it does grow out• the longer the insult, the wider the groove

• What it’s associated with:• trauma• chemotherapy• systemic illness

Leukonychia Punctata

Leukonychia PunctataWhat it is:• minor trauma to nail cuticle or matrix

What you see:• non-uniform lines or spots• can be single or multiple• it does grow out

What it’s associated with:• minor trauma

When did this trauma occur?

Mee’s lines

Mee’s linesWhat it is:• nail bed ok but nail itself is microscopically

fragmented

What you see:• milky white transverse bands• seen in single or multiple nails• grow distally with time• width varies with the insult

• What it’s associated with:• heavy metal poisoning (arsenic, thallium)• leprosy• malaria• carbon monoxide poisoning• renal and heart failure• chemotherapy• Hodgkin’s disease

Longitudinal LinesA) Longitudinal

ridging

B) Splinter hemorrhages

C) Melanoma

D) Pigmented bands

E) Habit tic deformity

F) Median nail dystrophy

Longitudinal Ridging

What it is:• partial dropout or malfunction of the nail matrix, which thins the nail plate

What you see:• longitudinal elevations that alternate with depressions or grooves along the nail

• What it’s associated with:• being elderly• lichen planus (can be severe)• not associated with vitamin deficiencies

Melanoma vs. pigmented bands•New longitudinal band in a light-skinned person

•Sudden change in appearance of band (e.g., proximally wider, darker, blurred border)

•Single-nail involvement (especially thumb, index finger, or great toe)

•Pigmentation of the skin of the nail fold or proximal nail bed (Hutchinson's sign)

•New pigmentation in older persons (>60)

•Band width of more than 3 mm

•Family history of melanoma or dysplastic nevi

•Abnormal nail structure (i.e., destruction or disruption of the nail plate)

Splinter Hemorrhages

What it is:• hemorrhage of the distal capillary loop

What you see:• longitudinal hemorrhage

• What it’s associated with:• subacute bacterial endocarditis• trauma (usually distal)• lupus, RA, APLA• pregnancy• psoriasis

Median nail dystrophy, habit-tic deformity, and splitting

Damage to the matrix

Self-inducedBenign

Nails and Colors

A) Terry’s nails

B) Trauma

C) Pseudomonas

D) Yellow nail syndrome

Terry’s nailsWhat it is:• due to a decrease in vascularity and an increase in connective tissue in the nail bed

What you see:• white nails except for distal pink band• loss of the lunula• usually all the nails

• What it’s associated with:• Cirrhosis (80% of cases)• Diabetes• CHF• Hyperthryoidism• Malnutrition

Pseudomonas vs. Trauma

Treatment:• cut the nail as far back as possible.

• apply gentamicin otic solution bid

• alternatives include soaking in vinegar or treating with oral cipro(500mg bid x 2 weeks)

• may need to co-treat for fungal infection

Treatment:• bore a sterile hot needle through the base of the nail

• make sure you are wearing ocular protection

• almost instant relief

• watch for Beau’s lines to develop!

Yellow nail syndromeWhat it is:• delayed nail growth with associated microvascular permeability

What you see:• yellow, thickened nails• can see loss of the lunula• usually all the nails

• What it’s associated with:• Lymphedema• Pleural effusion• Hypoalbuminemia• Bronchiectasis• RA

Fun pimping

• How do you detect clubbing?

• What is the sign called?

• What conditions are associated with clubbing?

Clubbing

Associated conditions: Inflammatory bowel disease, lung cancer, asbestosis, chronic bronchitis, COPD, cirrhosis, congenital heart disease, endocarditis, fistulas

Nail biting

What is the single best lifestyle modification to prescribe?

Nail biting

What is the single best lifestyle modification to prescribe?

Increased physical activity!!!

Spoon nails - Koilonychia

What are the two most common conditions associated with spoon nails in adulthood?

Spoon nails - Koilonychia

What are the two most common conditions associated with spoon nails in adulthood?

1. Iron deficiency (Plummer-Vinson syndrome)

2. Hemochromatosis

Periungal telangectasias

What group of disorders is most commonly associated with periungal telangectasias?

Periungal telangectasias

What group of disorders is most commonly associated with periungal telangectasias?

Connective tissue diseases, especially scleroderma

References

• Fawcett et al. Nail Abnormalities: Clues to Systemic Disease. Am Fam Physician 2004;69:1417-24.

• Dermnet.com (for images of several nail disease)

• Habif. Clinical Dermatology. 4th edition.