Nail Diseases

Beau’s lines
(Figure 3.58D)

Transverse depression in nail plate
surface

Severe systemic event (all nails) or
trauma/disease of matrix (single nail)

Soft nail plate

Koilonychia
(Spoon nails)

Thin, concave nails with eversion of free nail edge

Hereditary, physiologic (children), iron deficiency, thyroid abnormality

Opaque or completely white nail plate

Chemotherapy, white superficial
onychomycosis, congenital disease

White macules on nail plate

Psoriasis (PSO), trauma to matrix

Leukonychia, transverse
(striate) (Figure 3.57E)

Narrow white transverse lines along nail plate

Trauma to matrix

Transverse lines of entire nail breadth in all nails

Arsenic poisoning, trauma, medications, severe illness, PSO (flare)

Onychomadesis
(Nail shedding)

Detachment of nail plate from proximal nail fold (PNF) → shedding of nail

Traumatic, medications (i.e. chemo), drug reaction (i.e. TEN), autoimmune diseases, systemic illness

Onychorrhexis
(Figure 3.58E)

Longitudinal ridging, ± fissuring of plate

Lichen planus, chronic trauma, repeated wet/dry cycles, normal with aging

Pitting
(Figure 3.57A)

Punctate depressions of nail plate surface

{Elkonyxis: large 2-mm pits}

Psoriasis (PSO), alopecia areata,
eczema

Pink to red spots within lunula

Alopecia areata, rheumatoid arthritis, LE, CHF, CO poisoning

Trachyonychia (20 nail
dystrophy) (Figure 3.57C)

Rough, thinned nails with longitudinal ridging

Alopecia areata, lichen planus (LP), PSO, eczema

White discoloration (fades with pressure); nail plate looks white but normal color

Drugs (i.e. chemo agents) or systemic disease

Oil spots
(Figure 3.57B)

Brown spots under nail plate

PSO

Onycholysis
(Figure 3.57F)

White discoloration at distal end where nail plate separated from bed

PSO, trauma, onychomycosis, medications (TCN, NSAID, PUVA), tumors, systemic diseases (hyperthyroidism), pregnancy

Splinter hemorrhages
(Figure 3.59A, B)

Rough, thinned nails with longitudinal ridging

Alopecia areata, lichen planus (LP), PSO, eczema

Half and half nails
(Lindsay’s nails)
(Figure 3.59C)

Proximal ½ with white zone, distal ½ with red-brown zone

Chronic renal disease

Periungual black discoloration

Melanoma

Transverse white bands parallel to lunula

Hypoalbuminemia, chemotherapy

Partial or diffuse

Drugs, melanoma, Laugier-Hunziker

Longitudinal melanonychia
(Melanonychia striata)
(Figure 3.58F)

Vertical brown-black band (proximal to distal margin)

{Common in darkly pigmented skin types}

Nevus, lentigo, drugs, trauma, melanoma

Terry’s nails
(Figure 3.59D)

Proximal 2/3 white nail color, distal
1/3 brown-pink band

Cirrhosis, hypoalbuminemia, diabetes, cardiac disease

No visible lunula

Yellow nail syndrome, renal failure, trauma

Absence of nail

Nail patella syndrome, COIF, (Congenital Onychodysplasia of the Index Finger) scarring

Blue discoloration of lunula

Wilson’s, drugs, PUVA, argyria, etc.

Short, wide nails

Rubinstein-Taybi syndrome, PSO

↑ Nail curvature w/ bulbous growth of tip of digit

Chronic pulmonary disease, idiopathic, familial, systemic disease

Long nails

Marfan’s, Ehlers Danlos, etc.

Dorsal pterygium
(Figure 3.58C)

Wing-like growth fusing PNF with nail bed/matrix

Lichen planus, epidermal bullosa, TEN, GVHD, TEN, cicatricial pemphigoid

Habit tic deformity
(Figure 3.58A)

Parallel horizontal grooves

Caused by repetitive trauma to cuticle

Large nails

Congenital abnormality

Median canaliform dystrophy
(Figure 3.58B)

Inverted ‘fir tree’(oblique lines from midline defect)

Idiopathic or inherited

Small nails

Congenital defect (i.e. COIF)

Hypertrophic nail plate

May be due to chronic trauma

Reduction in size and thickness of nail plate

LP, vascular insufficiency, systemic disorders, medications

Ingrown nail

Grossly thickened and long nail, resembling claw

Inability to cut toenails, long-term pressure (i.e. shoes), neglect

Nail biting

Onychoschizia
(Lamellar nail splitting)

Distal lamellar separation into horizontal layers

Repeated wet and dry cycles, trauma, systemic disease and medications

Chronic picking of nail

Thickened nails

Pachyonychia congenita

Overcurvature lateral portion

Pressure (ill-fitting shoes), hereditary

Flat nail

Inherited or acquired

Distal phalanx short/wide

Form of brachyonychia

Subungual exostosis
(Figure 3.59E, F)

Painful, bony subungual growth elevating nail plate

X-ray confirms bony exostosis

Triangular shape of lunula

Nail-patella syndrome

Ventral pterygium
(Pterygium inversum unguis)

Fusion of hyponychium to distal nail plate

Familial, trauma, systemic sclerosis, lupus erythematosus

Yellow color to nail plate

Yellow nail syndrome, drugs, chronic enamel

{Yellow nail syndrome: pulmonary disorder + lymphedema + yellow, slow growing nails with absent lunulae}

V-shaped nicking
(Figure 3.57D)

V-shaped nick at free margin

Darier disease