*Changes in nails can be caused by genetics, dryness, medications, trauma, or systemic processes

·          Genetics: white lines in nails

·          Dryness: splitting, cracking (look at cuticle area); your nails take 300x more H20 than skin.  Tx: ointment based moisturizer, emollient for cuticles, do not push back cuticles

·          Medications: “any recent changes in medications?”

·          Mild trauma can induce nail changes 

·          Systemic: common cause is chemotherapy, psoriasis, lichen planus


Acute Paronychia: Painful, bright red swelling of the proximal and lateral nailfold.  May occur spontaneously or may follow trauma or manipulation.  Superficial infections may develop with an accumulation of purulent material behind the cuticle

Chronic Paronychia: Inflammation of the proximal nailfold.  Evolves slowly and presents initially with tenderness and mild swelling at the proximal and lateral nailfolds.  A major cause is significant contact irritation (individuals who are repeatedly exposed to moisture). Typically many or all fingers are involved simultaneously.

Pseudomonas Infection

When there is repeated exposure tosoap and water, this causes maceration of the hyponychium and softening of the nail plate.  Separation of the nail plate (onycholysis) exposes a damp, macerated space between the nail plate and nail bed which is a fertile site for the grown of Pseudomonas. The nail plate turns a green-black color, with little discomfort or inflammation (may be confused with subungual hematoma but this is painful).

Tinea Unguium/Onychomycosis

Most commonly caused by T. Rubrum and T. Mentagrohytes but may also be caused by Candida.  Nail infection may occur simultaneously with hand or foot tinea or may occur as an isolated phenomenon. Trauma predisposed to infection


Painless separation of the nail from the nail bed.  Usually begins at the distal groove and progresses irregularly and proximally causing part or most of the plate to become separated.  The nonadherent portion of the nail is opaque with a white, yellow or green tinge.  Can be caused by trauma, psoriasis, Candida or Pseudomonas infections, internal drugs, contact with chemicals, maceration from prolonged immersion and allergic contact dermatitis. Known to be associated with thyroid disease


Incidence of nail involvement varies from 10-50%.  May occur simultaneously with skin disease both may occur as an isolated finding.  Pitting or sharply defined ice pick-like depressions in the nail plate is the most common finding.  The number, distribution, patterns and depth vary

Lichen Planus

Nail LP usually appears during the 5th or 6th decade of lift.  Most common characteristics are minimal inflammation of the matrix inducing longitudinal grooving and ridging.  May also see development of severe and early destruction of the nail matrix with scarring.  Nail LP is usually self-limiting.  Permanent damage to the nail is uncommon. 

Alopecia Areata

Shallow pitting or surface stippling in a uniform or grid-like pattern

Median Raphe: self-induced trauma caused by habit of rubbing nails, typically thumbnails

Yellow Nail Syndrome

Key features:

·          Arrest in nail growth

·          Yellow-green nails

·          Absence of the cuticle

·          Overcurvature and thickening

·          All or most nails are affected

First described by Samman and White in 1964.  UNCOMMON and pathogenesis is UNKNOWN.

Linear nail growth is arrested or greatly reduced.  Nails are thickened and transversely and longitudinally overcurved with no appearance of the cuticle.  Nail color varies from pale yellow  to dark green.  Onycholysis is frequently seen as is nail plate shedding.  In most cases, all 20 nails are involved.  Characteristically, this abnormality is associated with lymphedema and respiratory tract involvement, including chronic bronchitis, bronchiectasis, sinusitis and pleural effusions.  The diagnosis however, only requires the presence of typical nail changes.

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