Hampshire Cure Fungal Nail Clinic

Common Nail Conditions and Presentations

Our nails can be easily damaged. Your skin and body need the right levels of hormones, nutrients, vitamins, blood, and oxygen in order to function at their best. If these are disrupted, become imbalanced, compromised, nail growth and associated structures can be affected.

Presenting nail imperfections are insidious in nature; developing very slowly or seemingly appear overnight. It can be hard to diagnose what the primary problem is and how to treat it. Many nail conditions can manifest as the same problem or exhibit similar nail plate issues. Here is a helpful guide to common nail plate disorders which are seen by podiatrists in clinic.

HORIZONTAL, TRANSVERSE LINES

BEAU'S LINES

Beau's lines are horizontal, transverse indentations, ridges, that run across nail plates. This very common nail plate manifestation is caused by an interruption of nail growth in the nail matrix. Causes:

Illness, stress causing fever, affecting circulation to nail matrix
· Injury to nail matrix
· Micro-trauma to nail plate e.g. poor fitting footwear
· Chronic health problems e.g. Raynaud’s Disease, diabetes, vascular disease
· Chronic skin conditions e.g. psoriasis, eczema
· Poor diet, vitamin deficiencies e.g. zinc
· Covid-19

Beau’s lines can indicate that for whatever health reason you had a health issue whichh interrupted nail growth. Normal growth does generally resume, and the lines grow out, but if they continue to form or effect multiple nails then that could be a sign of a more serious condition e.g. Onychomadesis which is worth getting checked out.

ONYCHOMADESIS

Onychomadesis presents as a proximal separation of the nail plate from the nail matrix. It is a temporary cessation of nail growth. It can be viewed as a severe form of Beau’s lines. Causes:·

Trauma· e.e repeated micro trauma, ill-fitting footwear
Reaction to medication·
Paronychial infection·
Autoimmune disease·
Major medical illness e.g. diabetes, vascular disease
Vascular insufficiencies e.g. Raynalds Disease
Poor diet, zinc deficiency
Bad manicures or pedicures
Covid-19
·Reduced levels of oestrogen
Dermatological skin and nail conditions e.g. psoriasis, eczema

In time normal nail growth should resume if the underlying cause is addressed, but if left to become a long standing chronic condition permanent disruption of nail growth may occur termed Anonychia.

MUEHRCKE LINES

These are transverse lines white and dark pink lines going horizontally across whole of nail plate. A condition caused by variable blood flow and increased pressure in the nail bed under the plate. Pressure on the nail plate makes them disappear. They are not grooved like Beau’s lines and not caused by trauma or interruption to nail growth. They do not grow out with the nail plate. They can be an indicator of a Hypoalbuminemia. This is decrease of protein synthesis which can occur during periods of metabolic stress. Other causes of Muehrcke Lines:

Systemic infection
AIDS·
Chemotherapy·
Kidney disease
Covid-19
Extreme changes in peripheral circulation e.g., altitude and temperature

The lines remain visible as long as protein intake is inadequate or synthesis is impaired, and they should disappear upon return to normal function.

LONGITUDINAL, VERTICAL LINES

ONYCHORRHEXIS

Onychorrhexis is the appearance of linear vertical lines forming on either finger and toenail plates. Nails are grooved or ridged and one or several nails can be affected. The nail plate can keep splitting from distal free edge and catch. Causes for developing the ridges are:

·Aging
Lichen Planus
Underlying health conditions e.g., thyroid disease, vascular disease
Anemia
Vitamin, mineral deficiencies e.g., iron, folic acid
Protein deficiency
Autoimmune disease e.g., rheumatoid arthritis, gout
Trauma e.g., nail picking
Poor manicures, pedicures,
Chemical contact
Lichen Planus

Onychorrehexis is a common finding in lichen planus as it with aging nails. A chronic presentation of onychorrexis is called Trachyonychia.

TRACHONYCHIA

Trachonychia is when there are multiple transverse ridges affecting the health and structure of the nail plate. Commonly termed as ‘rough nails’. Nails become opaque, lose their shine and become either thick or fine and fragile. The cuticles become thickened and ragged.

Less common is a shiny form of trachyonychia. The nails have more uniform ridges and pitting. It can occur in all age groups and seen more frequently in children.

Causes for trachyonychia are idiopathic, but they can develop as a secondary presentation to other primary dermatological conditions; conditions: ·

Lichen planus·
Psoriasis· Alopecia·
Immunoglobin vitamin A deficiency·
Dermatitis

Trachyonychia in a non-scarring process. In time the condition can spontaneously resolve as in cases of psoriasis. Trachyonychia nails are often misdiagnosed as onychomycosis or nail lichen planus. Mycotic nails can have a similar appearance especially when the fingernails are affected. ’ve been at it, and what got them to where they are.

DISCOLOURING OF NAILS

LEUKONYCHIA

Leukonychia is the appearance of white spots on the nail plate. Common forms of leukonychia are caused by trauma to the nail matrix. The white spots grow out with the developing nail plate. Other etiological causes. There can be cases of Leukonychia which are symptom of a more serious underlying condition. These are classified into total and partial forms:

1. Total leukonychia – whitening of whole nail plate

2. Partial leukonychia – has 3 subtypes:

Punctate - small white spots appear within nail plate. Commonly caused by trauma, but associated with psoriasis, lichen planus, alopecia, zinc deficiency, reflex sympathetic dystrophy, epilepsy and renal transplants
Transverse - Lengthwise white bands. This is considered to be the true form of leukonychia. Cause are repeated impact trauma to free edge of the distal nail plate, blood disorders e.g. leukaemia, neurovascular, dermatological skin disorders e.g. psoriasis, chemicals contact, drugs, infections, hormonal and other systemic conditions e.g. heart and kidney disease
Longitudinal Longitudinal lines, streaks, bands through the nail plate

GREEN NAIL- PSEUDOMONAS BACTERIAL INFECTION

Green nail syndrome (chromonychia) is a nail disorder characterized by lifting (onycholysis) and green-black discoloration of the nail bed. There can be an associated chronic paronychia. It is caused by a bacterial infection which invades underneath the nail plate. It is a pseudomonas infection. Causes are:

Nails regularly immersed in water
Trauma
Bad manicures/ pedicures e.g., poor hygiene
Wearing gel nails, varnishes

Nails damaged by a pseudomonas infection can be vulnerable to becoming fungal infected.

LIFTING OF NAIL PLATE

ONYCHOLYSIS

This is a presentation of the nail plate when it begins to separate and lift off the nail bed primarily from the distal edge. The nail plates seal: the onychodermal band gets damaged allowing the plate to lift off. There are numerous causes for onycholysis.:

·Damage to nail plate – trauma, chemicals, overzealous file cleaning
Pprolonged water immersion
Anaemia
Thryroid problems·
Diabetes
Lupus
Psoriasis
Bacterial nail infections
Yeast and fungal infections
Lichen planus
Dermatitis
Nail tumours
Medication e.g. Tetracycline, Griseofulvin, Retinoids
Congenital or hereditary

Damage to the nail plate can be reversible, if the cause is identified early and the correct treatment commenced. The longer that a nail presents with onycholysis permanent damage to the fine thread like attachments can ensue, and the onychodermal band does not regenerate.

ONYCHOMYCOSIS

Onychomycosis is fungal nail disease. Many of the previously mentioned nail conditions can be misdiagnosed as being fungal in nature. Fungal toenails are more common than infected fingernails. Approximately 15% of the population have fungal nail disease, and it is more prevalent in Western developed countries. The rates of infection increase with advancing age and compromised health and immunity. Younger individuals have slower developed infected nails than older ones. Common predisposing etiological factors are:

Repeated micro-trauma to nails e.g., poor biomechanics, ill-fitting footwear
Direct trauma
Diabetes
Weakened immune system
Venous insufficiency, poor circulation in the legs
Fungal skin infections on other parts of the body
Prolonged courses of antibiotics

The most common infective dermatophyte is Trichophyton Rubrum, which is responsible for most nail plate infections. It is highly opportunist, so when a nail plate is damaged it finds an easy way to invade the nail plate. It digests and breaks down the keratin to leave nails looking discoloured, crumbly, thickened, split and distorted. Infections can be superficial on the surface of the nail or penetrate deeply in the lower layers of the plate.

The more proximal the infection migrates towards the nail matrix the harder it is to treat. The main challenge in effectively treating onychomycosis is to eliminate all infectious fungal spores. Dormant spores can harbor in footwear, socks and shower areas and remain dormant for quite some time before they become active. They become active and infectious when the conditions are right for them to colonise the skin (Athletes Foot) and nails.

Occasionally, a bacterial infection can occur on top of a fungal nail infection or vice versa. Nails can look darkly discoloured having developed a pseudonomas infection termed 'green nail'.

SPLINTER HAEMORRHAGES

Splinter hemorrhages look like thin, red to reddish-brown lines of blood under the nails. They run in the direction of nail growth and are small thin streaks of clotted trapped blood product. They are caused by trauma and haemorrhaging of tiny capillaries subungually under the nail plate. The blood gets trapped until it grows out with the nail. Splinter haemorrhages can appear in thickened nails and in onycholysis. They are a diagnostic indicator of micro-trauma to the nail plate.

Nail splinter haemorrhages can be an indicator of more serious underlying health issues e.g. infections of the heart valves (endocarditis) of the heart valves (endocarditis)

OTHER DERMATOLOGICAL NAIL CONDITIONS

NAIL LICHEN PLANUS

This is a benign, chronic disorder affecting the skin and nails. The incidence of nail lichen planus is similar to that of onychomycosis/ nail fungus. Often the 2 conditions get mixed up with each other, but lichen planus affects fingernails more than toenails.

The many nail abnormalities found in nail lichen planus depends on its presentation; whether the nail matrix or nail bed is affected. The nail plate can have linear ridges (Onychorrhexis), showing thinning, splitting, and be thickened. There can be subungual hyperkeratosis (skin thickening). The nail plate can detach from the nail bed (onycholysis). White spots (leukonychia) or pigmentation (melanonychia) can be observed in the nail plate to confuse the picture.

A fungal nail test and taking a good history will help to diagnose correctly. One of the presentations that lichen nails can exhibit which other nail conditions don’t is the formation of a pterygium. A pterygium is a cutaneous overgrowth of tissue arising from proximal nail fold that fuses with the nail matrix and bed. It can result in the nail plate irreversibly splitting into 2 segments. The development of a pterygium can appear in approximately 50% of patients with nail lichen planus.

Causes for nail lichen planus are not fully understood, but appear to be connected with the compromisation of the immune system and reactions to certain medicines. If it is treated early enough with topicals or oral medication, the associated inflammatory responses can be dampened to reduce further advancement of the condition and subsequent damage. Nail lichen planus can be resolved, but unfortunately in more chronic cases, nails can be permanently damaged.

PTERYGIUM

A pterygium is a benign neoplasm of the nail unit. It is a cutaneous overgrowth of tissue arising from proximal nail fold, the eponychium. It fuses with the nail matrix and bed. It can result in the nail plate irreversibly splitting into 2 segments. The development of a pterygium can appear in approximately 50% of patients with nail lichen planus.

A pterygium must not be confused with thickened, ragged cuticles or the eponychium. Cuticles are dead skin at the base of nails that attach directly to the nail plate acting as a seal. Overzealous trimming and pushing back of cuticles can allow pathogens to enter into the nail matrix and potentially cause a paronychial bacterial infection

PSORIATIC NAILS

It is estimated that approximately 50% of individuals who have psoriasis have affected nails. Psoriasis normally affects several finger or toenails. It is more common in the fingernails. Pain and tenderness from nail psoriasis can impact daily activities. Nail psoriasis can be misdiagnosed alongside lichen planus and onychomycosis as it exhibits many similar features.

Common features of nail psoriasis:

Pitting — shallow or deep holes in the nail
Deformation — alterations in the normal shape of the nail
Thickening of the nail
Onycholysis — separation of the nail from the nail bed
Discoloration — unusual nail coloration, such as yellow-brown

Nail changes may occur on the nail plate or in the nail bed or nail matrix. Manifestations can be mild or severe. Treatments are determined by history and presentation. Psoriasis also affects the skin or joints. It is not common for there to be nail psoriasis without other associated symptoms.

PARONYCHIA

Paronychia is a bacterial infection of the skin around a fingernail or toenail. Paronychia infections can be divided into acute and chronic. The invading bacteria are

Staphylococcus aureus, followed by streptococci and pseudomonas organisms. Gram-negative organisms, herpes simplex virus, dermatophytes and yeasts have also been reported as causative agents.

Pathogens enter into the nail matrix and undermine more distally under the nail plate. The infected area can become swollen, red, and painful, and a pus-filled blister (abscess) may form. Paronychial infections can lead to onychomadesis, and in more chronic cases anonychia, permanent nail loss.

A paronychia of either finger or toenails must not be confused with a Whitlow. A Whitlow is an infection of the fingertip.

DOUBLE NAIL PLATES - RETRONYCHIA

The manifestation of several nail plates growing out from the nail matrix is relatively. More uncommon is Retronychia, when an emerging nail plate grows backwards to ingrow into the proximal nail fold. This can lead to pain and inflammation requiring nail surgery. Double nail plates growing forward give the appearance of a thickened yellow nail. They can become an issue when they start to separate from each other or become ingrowing. Trauma is the main etiological cause.

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