2012.3-2.A study of nail

DOI: 10.7241/ourd.20123.38                                                                                  article in PDF
Our Dermatol Online. 2012; 3(3): 164-170 
Date of submission: 14.01.2012 / acceptance: 20.02.2012 
Conflicts of interest: None

Neerja Puri, Tejinder Kaur

Department of Dermatology and Venereology, G.G.S. Medical College & Hospital, Faridkot. 151203. Punjab, India

Corresponding author: Dr. Neerja Puri    e-mail: neerjaashu@rediffmail.com


Nails act as a window to diagnosis of skin diseases. Various dermatosis affect the nails and the severity of the skin disorder is reflected in the nails. Nail changes are seen in various dermatosis like psoriasis, lichen planus, onychomycosis, collagen vascular disorders, vescicobullous disorders and other papulosquamous disorders. We will discuss in detail regarding nail changes in various dermatosis.
Paznokcie są jak okno w diagnostyce chorób skóry. Różne dermatozy wpływają na paznokcie a ciężkość choroby skóry ma swoje odbicie na stanie paznokci. Zmiany w paznokciach widoczne są w różnych dermatozach takich jak łuszczyca, liszaj płaski, grzybica paznokci, kolagenowa choroba naczyń krwionośnych, zaburzenia pęcherzowe i inne zaburzenia grudkowo-złuszczające. Omówimy szczegółowo zmiany paznokci w różnych dermatozach.
Key words: nail disease; psoriasis; onychomycosis; lichen planus
Słowa klucze: choroby paznokcia; łuszczyca; onychomycosis; liszaj płaski


Nail disorder comprises approximately 10% of all dermatological condition [1,2]. Any portion of the nail unit may get affected by various dermatological condition, systemic disease, infections, ageing process, internal and external medication, vascular insufficiency, physical and environmental agents, trauma, neurological abnormalities, nutritional deficiency and both benign and malignant tumour [3]. Various nail abnormalities result in pain or interference with functioning or both. Nail disorder may affect walking, picking up of fine objects and protective function. The increasing emphasis on the aesthetic consideration in dermatology means even the slightest nail change may assume significance for the patient [4]. Abnormal nails are of utmost clinical importance, especially when they are the only presenting feature without any other apparent signs and symptom of a disease. Hence nail provides us insight of window looking through which one can establish the diagnosis. Various dermatological conditions that characteristically involve the skin and hair may also involve the nail. The following is the classification of nail disorders:
1. Genetic disorders: Epidermolysis bullosa, congenital onychodysplasia of index finger, Racket nail, Dolichonychia, ichthyosis, incontinentia-pigmenti, acrodermatitis enteropathica.
2. Nail changes in infections: Various fungal, bacteria, viral, spirochete, yeast, HIV infection, leprosy may affect the nail.
3. Nail changes in dermatological conditions: Lichen planus, psoriasis, eczema, alopecia areata, vitiligo and pemphigus vulgaris.
4. Nails in systemic conditions: – Cardiovascular diseases. – Impaired peripheral circulation. – Renal diseases: nephrotic syndrome. – Respiratory diseases: tubercular empyema. – Endocrine disorder: hypothyroid, hyperthyroid, diabetes mellitus. – Gastrointestinal and hepatic disorders.
5. Nail deformities due to trauma: Nail biting, nail picking, habit-tic deformity, Heller’s dystrophy, hang nails and ill fitting shoes.
6. Occupational nail changes: Rickshaw pullers, housemaids.
7. Neoplasm of nails: Benign: like glomus tumour, myxoid cyst, periungual fibroma. Malignant: Malignant melanoma and squamous cell carcinoma.
8. Drug induced nail changes.
9. Cosmetics induced nail changes.
10. Nail changes in: Children, elderly, pregnancy. 
To study the abnormal nail changes in patients coming to the Department of Dermatology.
Material and Methods
For the present study, 500 patients with nail changes coming for various dermatological conditions was selected from the Department of Dermatology. A detailed clinical history regarding onset, duration and associated symptoms was asked. A thorough systemic and dermatological examination was conducted and all details were recorded on a special proforma. Routine investigations like Hb, TLC, DLC, ESR, platelet count, urine complete examination, blood urea, and serum creatinine were carried out to confirm the diagnosis. Special investigations like nail clipping for bacteriological and fungal infection, nail biopsy and skin biopsy were carried out whenever required.
The data was collected, analysed and the following results were obtained.
I. Age Distribution
The above table shows that maximum number of patients with nail changes (40%) were in the age group of 21-40 years, followed by 30% in the age group of 41-60 years, 20% were less than 20 years and 10% were in the age group 61-80 years.
Sr No Age No. of cases Percentage (%)
1 < 20 100 20
2 21-40 200 40
3 41-60 150 30
4 61-80 50 10

Table I. Incidence of nail changes among different age groups
II. Sex Distribution 
The above table shows that out of 100 patients, 52% were males, while 48% were females. Male to female ratio was 1.08 : 1. 
Sr No
No. of cases
Percentage (%)
1 Males 260 52
2 Females 420 48
3 Total 500 100

Table II. Sex distribution of patients with nail changes


III. Occupational Status 
Above table shows majority of cases i.e. 34% with nail changes were housewives, whereas 30% of cases were in service or business, 12% were students and 24% were labourers or farmers.
Occupational status No. of cases Percentage (%)
Housewives 170 34
Service\business 150 30
Students 60 12
Labourers\Farmers 120 24

Table III. Occupational status of patients with nail changes
IV. Number of Nails Involved 
Above table shows majority of cases i.e. 34% with nail changes were housewives, whereas 30% of cases were in service or business, 12% were students and 24% were labourers or farmers.
No. of nails No. of cases Percentage (%)
1-5 170 35
6-10 190 38
11-15 45 9
16-20 90 18
Total 500 100

Table IV. Number of nails involved
V. Nail changes in various dermatosis 
  The above table shows that majority of cases were of onychomycosis (25%), followed by psoriasis (20%), eczema (20%), paronychia (8%), lichen planus (5%) and dariers disease (4%), to name a few.
Sr No
 Dermatosis No. of cases
Percentage (%)
1 psoriasis 100 20
2  eczema  50 10
3 tinea unguim 125 25
4  lichen planus 25 5
5  paronychia 40 8
6  alopecia  5 1
7 secondary syphilis 4 0,8
8 leprosy 10 2
9  HIV 10 2
10 systemic sclerosis 10 2
11 pemphigus 5 1
12 drug induced 30 6
13 epidermolysis bullosa 2 0,4
14 periungual warts 15 3
15 atopic dermatitis 11 2,2
16 Dariers disease 20 4
17 PRP 7 1,4
18 pachyonychia congenita 1 0,2
19 twenty nail dystrophy 20 4
20 nail changes due to trauma 5 1
21 vitiligo 5 1
  total 500 100

Table V. Nail changes in various dermatosis
VI. Nail changes in psoriasis
It is clear from table VI, that pitting was the most common finding in psoriasis, accounting for 70 % cases. Next most common nail changes were subungual hyperkeratosis in 40% and onycholysis in 52% cases. Discoloration was found in 25% cases followed by paronychia in 10% cases. 
Splinter haemorrhages were seen in 12% and Beau’s lines were observed in 14% cases salmon patches in 10 % cases, longitudinal ridging in 12% cases, longitudinal melanonychia in 4% cases, perilunular erythema/red lunules in 5% cases and twenty nail dystrophy in 3% cases.
 Nail changes  No. of cases
Percentage (%)
Pitting 70 70
Subungual hyperkeratosis 40 40
Onycholysis 52 52
Discoloration 52 52
Paronychia 10 1
Splinter haemorrhage  12 12
Beau's line 14 14
Salmon patches 10 10
Longitudinal ridging 12 12
Dystrophy 6 6
Longitudinal melanonychia 4 4
Perilunular erythema/red lunules 5 5
Twenty nail dystrophy 3 3

Table VI. Nail changes in psoriasis (n = 100)
VII. Nail changes in lichen planus 
The above table shows that longitudinal ridging was the most common finding accounting for 24% cases. Next most common nail changes were pterygium in 16% and onycholysis in 16% cases. Longitudina melanonychia was found in 20% cases followed by dystrophy in 4% cases. 
Twenty nail dystrophy was seen in 8% and subungual hyperkeratosis was observed in 12% cases. 
Sr No
Nail changes No. of cases
Percentage (%)
1 pterygium 4 16
2 longitudinal melanonychia 5 20
3 longitudinal ridging 6 24
4 onycholysis 4 16
5 dystrophy 1 4
6 subungual hyperkeratosis 3 12
7 twenty nail dystrophy 2 8

Table VII. Nail changes in lichen planus (n = 25)


VIII. Types of Onchomycosis 
The above table shows that maximum number of patients with nail changes (40%) were in the age group of 21-40 years, followed by 30% in the age group of 41-60 years, 20% were less than 20 years and 10% were in the age group 61-80 years.
Sr No
Type No. of cases
Percentage (%)
1 distal lateral sub ungual onchomycosis 93 74,4
2 superficial white onchomycosis 5 4
3 proximal sub ungual onchomycosis 2 1,6
4 total dystrophic onchomycosis 25 20

Table VIII. Types of onchomycosis (n = 125)
IX. The etiologic distribution of twenty nail dystrophy 
The above table shows that the commonest cause of TND was idiopathic (45%). Other causes of TND were psoriasis in 25% cases, lichen planus in 20% cases and alopecia areata was seen in 10% cases.
Sr No
 Type No. of cases
Percentage (%)
1 psoriasis 5 25
2 lichen planus 4 20
3 alopecia areata 2 10
4 idiopathic 9 45
5 Total 20 100

Table IX. Nail changes in twenty nail dystrophy
X. Nail changes in paronychia 
The above table shows that absent cuticles and nail fold inflammation were the commonest nail changes seen in all the cases, discoloration in 70% cases, transverse grooves in 50% and onycholysis in 40% cases.
Sr No
 Nail Changes
No. of cases
Percentage (%)
1 absent cuticles 40 100
2 nail fold inflammation 40 100
3 subungual hyperkeratosis 6 15
4 onycholysis 16 40
5 discoloration 28 70
6 longitudinal striations 2 5
7 transverse grooves 20 50
8 nail dystrophy 2 5

Table X. Nail changes in paronychia
Nail disorders are seen in various dermatosis like fungal infection, psoriasis, lichen planus, vescicobullous and collagen vascular disorders. Onychomycosis represents a broad term for any fungal infection of any part of the nail unit by dermatophytes, molds or yeast [5]. Onychomycosis caused by dermatophytes is also called as tinea unguium. Fungal infection of nail may be classified as [6]: 1. Distal subungual onychomycosis primarily involves the distal nail bed and hyponychium. 2. Superficial white Onychomycosis is an invasion of the surface of the nail plate. 3. Proximal subungual onychomycosis involves the nail plate from the proximal nail fold. 4. Candidal onychomycosis involves all the nail plates [7,8,9]. There is true invasion of nail plate by candida albicans resulting in dystrophic nail. It occurs in patients with chronic mucocutaneous candidiasis. Nail involvement of one or all the nail component occur in 10% of patient with lichen planus [10,11]. Severe inflammatory focus in the nail matrix, leads to adhesion formation between epidermis of proximal nail fold and nail bed and result in pterygium formation, which is highly suggestive of LP. Other less common features include onycholysis, shedding of the nail, subungual hyperkeratosis, erythematous patches in the lunula, koilonychia, pitting and nail discolouration may also occur [12,13,14]. Psoriasis is a common disease affecting nails with subsequent dystrophy. Nail involvement has been reported up to 50% of case [15,16], but over a life time, the incidence cumulatively increases to 80-90%. In order of decreasing frequency, nail changes of psoriasis are pitting, onycholysis, subungual hyperkeratosis, nail plate discolouration, uneven nail surface, splinter haemorrhages [2] and lastly acute and chronic paronychia [17,18,19]. Nail changes are common in alopecia areata, ranging from 7% to 66% [20]. Nail changes are not only seen in extensive alopecia areata but may also be present with minimal hair loss and does not imply a poor prognosis for regrowth. Uniform pitting is the most common abnormality seen in alopecia areata. Pits are often uniformly arranged in lines both transversely and longitudinally in a geometrical or scotch plaid pattern [21]. Other nail changes include ridging, onychorrhexis, beau’s lines or transversely arranged pits, thinning or occasionally thickening of the plate, koilonychia, onychomadesis leading to nail shedding, leukonychia punctata due to nail bed dystrophy and lunules may be red or mottled. Round finger pad sign could be the early sign of scleroderma. Pterygium inversum unguis may be the helpful diagnostic sign in scleroderma [22]. It is characterized by obliteration of the distal groove due to adherence of the distal portion of the nail bed to the ventral surface of the nail plate. Other nail signs like onycholysis, longitudinal ridging, onychorrhexis, onychogryphosis, haplonychia, longitudinal striation, absent lunulae, periungual vesiculation has been reported in scleroderma. Parrot beak deformity is another distinctive feature of the disease characterized by over curvature of the free margins of the nail over a shortened finger tip. It is due to atrophy of the soft tissue. Twenty nail dystrophy (TND) is a condition in which all twenty nails are uniformly and simultaneously affected [23,24]. Earlier it was called as excessive ridging of childhood or Trachonychia [25]. TND can be idiopathic, congenital or acquired [26]. The acquired type may be related to variety of disorders like lichen planus, psoriasis, alopecia areata, ichthyosis vulgaris, eczema and perhaps Pemphigus. In our study, out of 500 patients,nail changes were seen in various dermatosis. Maximum number of patients (25%), were of onychomycosis (Fig. 1) followed by 20% patients of psoriasis (Fig. 2), 20% patients of eczema, 8%, patients were of paronychia (Fig. 3), 5% patients of lichen planus (Fig. 4) and 4% patient were of dariers disease to name a few. We had one patient of tuberous sclerosis with koenens tumour (Fig. 5). Out of 100 patients of psoriasis the most common changes were pitting, subungual hyperkeratosis, onycholysis and discoloration. Out of 125 cases of lichen planus, the most common changs were longitudinal ridging, pterygium and onycholysis. Twenty nail dystrophy was seen in 20 cases and the commonest cause of twenty nail dystrophy was idiopathic in 45% cases,psoriasis in 25% cases, lichen planus in 20% cases and alopecia areata was seen in 10% cases.
Figure 1. Distal lateral subungual onychomycosis
Figure 2. Pitting and onycholysis in a psoriasis
Figure 3. Paronychia with nail fold inflammatio
Figure 4. Pterygium formation in lichen planus

Figure 5. Koenens tumour

From the foregoing account, it can be concluded that a variety of nail changes can occur in various dermatological, systemic and other conditions. The nail unit is capable of only a limited number of reaction patterns, therefore, many diseases share similar changes, but correlation of the nail changes helps dermatologist to reach conclusive diagnosis. In order to evaluate the nail changes skillfully one must be familiar with the terminology and classification of the nail disorders. Thus knowing the normal and abnormal variants of the nail and their association with wide range of disease is beneficial not only for the establishing diagnosis but also for the specific management of the disease. Hence, no physical examination is complete without the study of nails. However, nails remain an understudied and yet quiet accessible structure that lends itself for examination and evaluation. Hence truly said that nails are the windows through which one can look into the health of the patients.
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