Nails

age-related nail changes

alcoholism

clubbing, koilonychia, red lunulae, Terry’s nails

alopecia areata

Beau’s lines, brittle nails, koilonychia, leukonychia punctata, longitudinal ridging, onycholysis, onychomadesis, pits, red nails, spotted lunulae, thickened nails

angel wing deformity

deformity of nail; lichen planus

anonychia

absence of all or portion of nail; Clouston syndrome, congenital, lichen planus, nail-patella syndrome

AZT

melanonychia

azure lunulae

bluish proximal nail bed; agyria, Wilson’s disease

bands; longitudinal pigmented

acrodermatitis enteropathica, Addison’s disease, AIDS, amyloid (primary), arsenic, carcinoma of breast, carpal tunnel syndrome, Cushing’s disease, fluorosis, gastrointestinal disease, hemosiderosis, hyperbilirubinemia, hyperthyroidism, hypopituitarism irradiation, Laugier-Hunziger s., malnutrition, melanoma (metastatic), ochronosis, Peutz-Jeghers syndrome, porphyria, pregnancy, syphilis (secondary)

bands; longitudinal white

Hailey-Hailey disease

beading

rheumatoid arthritis

Beau’s lines

transverse depression of nail plate; alopecia areata, b-blockers, cytotoxic drugs, dysmenorrhea, Kawasaki d., MI, nutritional deficiency, post fever, psoriasis

beta-blockers

Beau’s lines, digital ischemia, leukonychia (apparent), onychomadesis

blue nails

antimalarials, AZT, 5-flouracil, hematoma, Wilson’s disease

brachydactyly

pseudohypoparathyroidism

brachyonychia

AD; greater width than length of nail plate AKA racquet nail

brittle nails

dehydration, elderly, irritant contact, lichen planus, Marinesco-SjØgren s., nail polish, onychomycosis, psoriasis, retinoids

brown/black nails

AZT (esp. blacks), antimalarials, Peutz-Jeghers syndrome

canal

single wide groove from matrix pressure; myxoid cyst

chevron nail

V-shaped longitudinal ridging in children

chromonychia

abnormal nail color; external contactant, methemoglobinemia, systemic chemical absorption

clubbing

cuticle (Lovibond’s) angle greater than 180 degrees due to fibrovascular hyperplasia;

acrocyanosis, alcohol, amyloidosis (secondary), angiectasis, arsenic, Ascaris infection, beryllium, biliary cirrhosis, bronchitis, bronchiectasis, cardiopulmonary disease, CHF, chilblains, chronic myelogenous leukemia, Clouston’s syndrome, collagen vascular disease, congenital dysplasia, congenital heart disease, citrullinemia, cretinism, diarrhea (chronic-sprue), cyanotic heart disease, emphysema, endocarditis (subacute bacterial), familial, fibrosarcoma, GI neoplasm, Gottron’s syndrome, Graves’ disease, hepatic cirrhosis, hereditary sclerosing poikiloderma, Hodgkin’s disease, hypertrophic hypervitaminosis A, hypothyroidism (thyroid acropathy), osteoarthropathy, idiopathic, Kaposi’s sarcoma, leprosy, liver disease, lung abscess, lung cyst, lymphoma, Maffucci’s syndrome, mercury, mesoendothelioma, myxedema, myxoid tumor, neutropenia (chronic familial), pachydermoperiostosis, Peutz-Jeghers syndrome, phosphorus, pneumonia, POEMS syndrome, post-thyroidectomy, primary polycythemia, pseudotumor, pulmonary fibrosis, pulmonary neoplasm (<5%), Raynaud’s disease, rheumatic fever, scleroderma, SLE, sprue, syphilis, syringomyelia, tuberculosis, ulcerative colitis

clubbing-unilateral or unidigital

arterial aneurysm, brachial arteriovenous fistula, erythromelalgia, felon, gout (tophaceous), lymphangitis, median nerve injury, Pancoast’s tumor, sarcoidosis, shoulder subluxation, trauma

Darier disease (Darier-White disease)

distal V-shaped notch, red longitudinal subungual streaks, wedge-shaped subungual hyperkeratosis, white longitudinal subungual streaks

discoloration; topical agents that cause nail discoloration

black: phenol sulfate hydroquinone, red wine, silver nitrate

blue: cyanide, oxalic acid, silver

gray-blue: ammoniated mercury, mercuric chloride (with UV)

green: chlorophyll, copper salts

orange-brown: anthralin, Arning’s tincture, burnt sugar, chromium salts, chrysarobin, dinitrotoluene, dithranol, formaldehyde, flutaraldehyde, henna, hydroquinone, iodohydroxyquinolene, iron, mepacrine, nicotine, paraquat, pecan, picric acid, potassium permanganate, pyrogallol, resorcin, rivanol, roasted coffee, thermal injury, vioform, walnuts

purple: gentian violet

red: carbol-fuchin

yellow: amphotericin, dinitro-orthocresol, dinubuton, fluorescein, hydrofluoric acid

drugs

AZT, b-blockers, PUVA, retinoids

dyschromia

white/red longitudinal streaks; Darier-White disease, SCC in situ

proximal nail bed white, absent lunula; Terry’s nail

double white translucent bands; Muehrcke’s lines

distal brown; Lindsay’s nail

dysplasia, toenails

popliteal web syndrome

dystrophy

amyloidosis, Clouston’s syndrome, exfoliative erythroderma, glucagonoma s., KID syndrome, Olmsted’s syndrome, Rabson-Mendenhall syndrome, Rothmund-Thompson syndrome, Sabinas syndrome, trauma, Zinsser-Cole-Engman syndrome

dystrophy, median

habit tic, mucous cyst

dystrophy, occupational

motor oils, permanent wave solutions, solvents, trauma

eggshell nails

dull gloss, brittle, easily split nail

friable

nail enamel use, onychomycosis (superficial)

groove, longitudinal

Schopf-Schulz-Passarge syndrome (also see median canaliform dystrophy of Heller)

groove, oblique

Schopf-Schulz-Passarge syndrome

groove, transverse

AKA Beau’s line

growth, decrease rate of nail

acute infection, aging, antimitotoic drugs, cold climate, congestive heart failure, decreased circulation, females, hypothyroidism, paralysis, immobilization, lactation, malnutrition, measles, mumps, nighttime, peripheral neuropathy, pneumonia, smoking, systemic disease, yellow nail syndrome

growth, increase rate of nail

dominant hand, hyperpituitarism, hyperthyroidism, AV shunt, local repetitive trauma, longer digits, males, onycholysis, periungual inflammation, pregnancy, premenstrual, psoriasis, regeneration, warm climate

half and half nails

white proximal & brown distal nail (melanin); chronic renal failure, uremia AKA Lindsay’s nails

hard nails

pachyonychia congenita

harlequin nail

distal yellow stained nail & proximal clear nail after abrupt smoking cessation

Heller’s median canaliform dystrophy

split midline nail with fir tree-like appearance at backward angle; myxoid cyst, repeated trauma (picking at cuticle-typically the thumb nail)

hemionychia

nail-patella syndrome

Hippocratic nail

onychogryphosis

hook nail

bowing of nail due to lack of support of the short bony phalanx

Hutchinson’s sign

pigment leaching into nail fold; melanoma

hyperkeratosis, subungual

crusted scabies, Darier-White disease, lichen planus, Mal de Meleda, onychomycosis, pachyonychia congenita, pityriasis rubra pilaris, psoriasis, Reiter’s syndrome, Werner syndrome

hyperpigmentation

acrokeratosis verruciformis of Hopf, Laugier-Hunziger syndrome, panhypopituitarism

hyperpigmentation, chemotherapeutic agents

aminoglutethimide, bleomycin, busulfan, cisplatin, cyclophosphamide, cytarabine, dacarbazine, dactinomycin, daunorubicin, docetaxel, doxorubicin, etoposide, fluorouracil, hydroxyurea, idarubicin, ifosfamide, melphalan, methotrexate, mitomycin, mitoxantrone, tegafur, vincristine

ingrown

retinoids

koilonychia

alkalis & acids, alopecia areata, acanthosis nigricans, acromegaly, alopecia areata, anemia (chronic), Bantis syndrome, cachexia, chondroectodermal dysplasia (Ellis-van Creveld syndrome), coronary artery disease, Darier’s disease, ectodermal dysplasia, familial, focal dermal hypoplasia, frostbite, Gottron’s syndrome, hemochromatosis, hypothyroidism, hypovitaminosis B2 & C, idiopathic, incontinentia pigmenti, iron deficiency, LEOPARD syndrome, lichen planus, Mal de Meleda, malnutrition, monilethrix, nail-patella syndrome, Nezelof’s syndrome, normal children, occupational, onychomycosis, palmar hyperkeratosis, palmoplantar keratoderma, pellagra, petroleum products, Plummer-Vinson syndrome, polycythemia vera, porphyria cutanea tarda, post-gastrectomy, primary amyloid, psoriasis, Raynaud’s disease, renal transplant, scleroderma, sideropenic anemia, steatocystoma multiplex, syphilis, thyrotoxicosis, thermal burns, thioglyoclate contact (hairdressers) AKA spoon nail

leukonychia

white spots on nail plate due to matrix dysfunction; b-blockers, chilblains, dysmenorrhea, Hodgkin’s disease, idiopathic, leprosy, metastatic carcinoma, nephritis, psoriasis, tuberculosis

longitudinal; Darier’s disease

punctate; minor trauma

total; inherited

transverse; systemic disorder

lichen planus

angel wing deformity, atrophy, onycholysis, onychomadesis, onychorrhexis, pterygium, shedding, subungual hyperkeratosis, subungual hyperpigmentation, thinning

Lindsey’s nails

white proximal, red/brown distal nail; chronic renal failure AKA half & half nails

liver disease

brittleness, clubbing, flat nails, striations, watch-glass deformity, white bands, white nails

Lovibond’s angle

cuticle angle; greater than 180° indicates clubbing (see clubbing)

lunula, absent

endocrine, collagen vascular reticuloendothelial disease, normal variant

lunula, dyschromia

azure; hepatolenticular degeneration (Wilson disease)

red; alopecia areata, CHF, CO poisoning, collagen vascular disease

white; ischemia

yellow; tetracycline

lunula, red spotted

alopecia areata

lunula, triangular

nail-patella syndrome (pathognomonic)

lunula, ulceration

GVH disease

median canaliform dystrophy of Heller

split midline nail with fir tree-like appearance at backward angle; myxoid cyst, repeated trauma (picking at cuticle-typically the thumb nail)

Mees’ lines

paired narrow white transverse nail lines; antimony poisoning, arsenic exposure, cachectic state, carbon monoxide poisoning, carcinoid, cardiac insufficiency, childbirth, chemotherapy, crush injury, cryotherapy, endemic typhus, erythema multiforme, fluorosis, fracture, glomerulonephritis, gout, herpes zoster, Hodgkin’s disease, hyperalbuminemia, lead poisoning, leprosy, malaria, measles, menstruation, myocardial infarction, parathyroid insufficiency, pellagra, pneumonia, protein deficiency, psoriasis, renal failure, renal transplant, shock, sickle cell anemia, syphilis, systemic disease, thallium poisoning, tuberculosis, ulcerative proctitis, vitamin B12 deficiency, warm-reacting antibody immunohemolytic anemia, zinc deficiency

melanonychia

AZT, bleomycin, cyclophosphamide, ketoconazole, melanoma, minocycline, psoralen, PUVA

melanonychia, fungal

aspergillus, scitolytium, scopulariopsis

melanonychia, longitudinal multiple

Addison’s disease, AIDS, Cushing’s syndrome, folic acid deficiency, hyperthyroidism, vitamin B12 deficiency

melanonychia, transverse

cytotoxic drugs

micronychia

Clouston syndrome, nail-patella syndrome

Morton’s toe

2^nd toe longer than great toe, may become injured by shoes

Muehrcke’s nails, lines

paired white parallel transverse bands; hypoalbuminemia (2° to chemotherapy), nephrotic syndrome

nail plate thickening

chronic trauma, Darier-White disease, lichen planus, onychomycosis, pachyonychia congenita, psoriases, PRP, scabies (crusted)

nicotine sign

yellow discoloration of distal fingers & fingernails; smokers

notch, distal

Darier’s disease

oil drop sign

yellow-brown lesions under nail plate; psoriasis AKA salmon patch

onychochauxis

thickening, darkening, and irregular surface; diabetes mellitus, HIV, hypogonadism

onychodystrophy

alopecia areata, psoriasis

onychogryphosis

brown, thickened spiraled nail; footwear trauma, ichthyoses, impaired circulation, Mal de Meleda, onychomycosis, poor hygiene, psoriasis AKA ram’s horn nails

onychoheterotopia

ectopic nails

onycholysis

distal irregular separation of nail plate from nail bed; acrylic nail cement, allergic contact dermatitis, amyloid, anemia, bacteria, Bantu porphyria, bronchiectasis, carcinoma of lung, circulatory disorders, Cronkhite-Canada syndrome, CTCL, dermatitis, diabetes mellitus, drug reaction, eczema, erythropoietic porphyria, erythropoietic protoporphyria, formaldehyde, fungus, Graves’ disease, histiocytosis X, ischemia (peripheral), leprosy, lichen planus, lupus erythematosus, neuritis, panhypopituitarism, pellagra, pemphigus vulgaris, plasticizers, pleural effusion, porphyria, pregnancy, pseudoporphyria of hemodialysis, psoriasis, pustular eruption of pregnancy, Raynaud’s phenomenon, Reiter’s syndrome, scleroderma, Sezary syndrome, SCC, syphilis, thyroid disease, trauma, Vitamin C deficiency, warts, yellow nail syndrome

onychomadesis

shedding of nail plate; alopecia areata, b-blockers, thrombosis

onychomycosis

proximal & proximal white superficial; HIV, immunosuppression

immunosuppression, hyperhidrosis, diabetes mellitus, aging

onychomycosis

proximal subungual onychomycosis (HIV); Trichophyton rubrum, T. megninii

white superficial onychomycosis; T. mentagrophytes

nondermatophytes; Candida, Scopulariopsis brevicaulis, Hendersonula toruloidea (Scytalidium dimidiatum), Aspergillus sydowii

onychorrhexis

longitudinal grooves & ridges of nail plate; alopecia areata, lichen planus, normal with aging (mild)

onychoschizia

metabolic acidosis

Osler’s toe

onychogryphosis

paronychia, acute

thickened nails: infection, manicuring, retinoids, trauma

paronychia, chronic

thickened nails: biting, contactants, dermatitis, infection, psoriasis, sucking

parrot-beaking

widening onychocorneal band of finger nails; Unna-Thost disease

periungual infarcts

Wegener’s granulomatosis

photo-onycholysis

mercaptopurine, PUVA

pincer (trumpet) nails

footwear pressure, idiopathic, osteoarthritis, psoriasis, subungual exostoses

pitting

alopecia areata, atopy, basal cell nevus syndrome, chronic paronychia, Darier disease, eczema, fungal infection, lichen nitidus, lichen planus, normal variant, psoriasis, Reiter disease, reticulate acropigmentation of Kimura, rheumatoid arthritis, trauma

pseudo-Hutchinson’s sign

discoloration of matrix in subungual hematoma

pseudopyogenic granuloma

retinoids

psoriasis

grooves, leukonychia, oil drop sign, onychodystrophy, onycholysis, pitting, salmon patch, splinter hemorrhage, spooning, subungual hyperkeratosis

pterygium

scarring nail bed separation from matrix; dyskeratosis congenita, familial, idiopathic, progressive systemic sclerosis, Raynaud’s disease, Stevens-Johnson syndrome, trauma, vascular insufficiency

dorsal; bullous dermatosis, congenital, digital ischemia, LP, radiotherapy, trauma

ventral; causalgia, formaldehyde exposure, scleroderma with Raynaud phenomenon,  trauma, congenital

Quincke’s pulse

aortic insufficiency

racquet nail

AD; greater width than length of nail plate AKA brachyonychia

ram’s horn

onychogryphosis

rheumatoid d.

atrophy, capillary dilation, proximal erythema

ridging

CIE, Darier’s disease, lichen planus, normal elderly, peripheral vascular disease, RA

ridging; longitudinal

acrokeratosis verruciformis of Hopf, panhypopituitarism

salmon patch

yellow-brown subungual discoloration AKA oil drop sign; psoriasis

splinter hemorrhages

damaged longitudinal vessel of nail bed which exudes blood;

dermatologic: alopecia mucinosa, Darier’s disease, eczema, exfoliative dermatitis, keratosis lichenoides chronica, mycosis fungoides, onychomatricoma, pemphigoid, pemphigus, pen-push purpura, psoriasis, pterygium, purpura, polyarteritis nodosa, pityriasis rubra pilaris, porphyria, Raynaud’s disease

infectious: bacterial endocarditis, fungi, HIV, onychomycosis, psittacosis, trichinosis

medications: drug reaction, methoxsalen, tetracycline

miscellaneous: altitude (high), irradiation, normal variants, radial artery puncture, radiodermatitis, trauma, Vitamin C deficiency

systemic: amyloid, anemia, antigen-antibody complex disease, antiphospholipid coagulopathy, antiphospholipid syndrome, Behçet’s syndrome, Buerger’s disease, Carney complex, cirrhosis, cryoglobulinemia, cystic fibrosis, diabetes mellitus (10%), dialysis, emboli (arterial), histiocytosis X, Letterer-Siwe disease, leukemia, Osler-Weber-Rendu syndrome, malignancy, mitral stenosis, multiple sclerosis, glomerulonephritis, heart disease, hemochromatosis, hepatitis, hypertension, hypoparathyroidism, illness (chronic), peptic ulcer disease, pulmonary disease, rheumatic fever, rheumatoid arthritis, sarcoid, scurvy, septicemia, SLE, thrombocytopenia, transplant patients, trauma, thyrotoxicosis, vasculitis, Wegener’s granulomatosis

spoon nails

AKA koilonychia

telangiectasia, periungual

cystic fibrosis

telangiectasia, posterior nail fold

SLE, systemic sclerosis, dermatomyositis, RA, Raynaud’s syndrome

tennis toe

Morton’s toe distally injured by sporting events or small shoes

Terry’s nails

white proximal, distal pink nail (onychodermal band within 0.5-3mm of hyponychium); CHF, diabetes mellitus, liver cirrhosis, normal elderly

thickening

alopecia areata, congenital ectodermal defects, congenital malalignment of the great toe nails, Darier’s disease, Fischer-Jacobsen-Clouston syndrome, fungal infection, pachyonychia congenita, pityriasis rubra pilaris, psoriasis, trauma

thinning

alopecia areata

trachyonychia

rough, dull, brittle nails with frayed edges; alopecia areata, chemical exposure, eczema, idiopathic, lichen planus, psoriasis AKA twenty nail dystrophy

trumpet nail

AKA pincer nail

tumors in children

angiokeratoma, digital fibroma, enchondromas of Maffucci’s syndrome, exostoses, Koenen’s (angiofibromas of tuberous sclerosis), hemangiomas of blue rubber bleb nevus or Klippel-Trenaunay-Weber syndrome, incontinentia pigmenti, juvenile xanthogranuloma, osteochondroma, pyogenic granuloma

turtle back nail

Fabry’s disease

twenty nail dystrophy

see trachyonychia

warts, nail region

HPV-1, 2, 4

washboard nails

longitudinal depression affecting one or both thumb nails; habitually pushing back cuticle

watch glass deformity

mild clubbing with slight convex surface of nail; see clubbing

white

cirrhosis, cryoglobulinemia, Raynaud’s syndrome, selenium deficiency, systemic sclerosis

yellow

oxalic acid, Pneumocystis infection in AIDS, smoking, Touraine-Solente-Gole syndrome

yellow nail s.

yellow nails, absent cuticles, inccreased curvatur, diminished lunulae, onycholysis, slowed growth; bronchiectasis, carcinoma of larynx, chronic bronchitis, chronic lymphedema, pulmonary disease, rheumatoid arthritis, sinusitis, thyroid disease