Nails Examination and Disorders. Overview. Case 1 15/09/2016. Samantha Eisman. 25 year old woman Noticed at pedicure Single toe
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1 Nails Examination and Disorders Samantha Eisman Dermatologist MBChB/ MRCP/ FCDerm(SA)/ FACD Demystify nails Overview QUIZ Talk Examination nails and and site specific disease QUIZ answers and cover common nails disease MCQ 25 year old woman Noticed at pedicure Single toe Case 1 What is diagnosis? How would you diagnose? How would you treat? 1
2 Case 2 12 year old girl 4 nails Diagnosis? Treatment? Concerns? Case 3 8 year old twin 4 year history of nail problem left foot only. No help numerous topicals. Twin sister no nail issues. Family history psoriasis. Fungal mycotic elements only Case 4 50 year female nail problem months sister has nails problems skin NAD GP negative nail clippings Terbinafine for 1 year Diagnosis/Differential Diagnosis? Thought re terbinafine choice and length treatment? 2
3 Case 5 42 year old from South America No response to loceryl 6 months Diagnosis? Differential? Management? Case 6 What clinical signs are evident? What is the differential? What other skin manifestations may be present? What other nail changes can be present with this condition? Case 7 50 year old lady Housewife Concern re weak nails Medically well Diagnosis? Treatment? Preventions? 3
4 10 year old boy Teased at school Tried OTC products Case 8 Diagnosis? Management options? Concerns? Case 9 55 year old woman Few years hx of nail changes What is the diagnosis? Would the prognosis be different if one nail was affected? Nails Examination and Disorders Samantha Eisman Dermatologist MBChB/ MRCP/ FCDerm(SA)/ FACD 4
5 Nail Examination and site specific diseases of the nail Sites of nail disease 1.Nail plate 2.Nail colour 3.Nail fold and cuticle 4.Nail shape 5.Lesions around the nail 1.Nail plate Pitting Ridging Thickening ( onychogryphosis) Crumbling Splitting Rough ( trachyonychia) 5
6 Pitting Punctate depression nail plate Damage to matrix Psoriasis Alopecia areata Eczema 1.Nail plate Pitting Ridging Thickening ( onychogryphosis) Crumbling Splitting Rough ( trachyonychia) Ridging Transverse Longitudinal Beau s lines Eczema Psoriasis Paronychia Habit picking Aging Lichen planus Psoriasis Fungal 6
7 1.Nail plate Pitting Ridging Thickening ( onychogryphosis) Crumbling Splitting Rough ( trachyonychia) Thickening Rams horn nails Elderly/ Psoriasis/ Trauma 1.Nail plate Pitting Ridging Thickening ( onychogryphosis) Crumbling Splitting Rough ( trachyonychia) 7
8 Crumbling Tinea Psoriasis 1.Nail plate Pitting Ridging Thickening ( onychogryphosis) Crumbling Splitting Rough ( trachyonychia) Splitting: Distal = lamellar onychoschizia Distal edge Repeated soaking in water/ detergent 8
9 Splitting: Longitudinal Extension of ridging Psoriasis/ Fungal/ Lichen Planus 1.Nail plate Pitting Ridging Thickening ( onychogryphosis) Crumbling Splitting Rough ( trachyonychia) Rough Sandpapered nails 20 Nail dystrophy Psoriasis/ Lichen Planus/ Alopecia Areata 9
10 2.Nail Colour Yellow Green White Purple/Black Streaks Yellow Yellow Nail Syndrome Yellow/ green Hard Elevated longitudinal curve Loss cuticle/ pain/ shed Associated medical disease Fungal/ Psoriasis 2.Nail Colour Yellow Green White Purple/Black Streaks 10
11 Green Green Nail Syndrome: Pseudomonas Keep nail short Vinegar soaks Yellow Green White Purple/Black Streaks 2.Nail Colour 1.Trauma manicuring White 2. Superficial White Onychomycosis chalky white spots 11
12 3. Onycholysis Distal nail plate detached Detached nail white/ yellow Causes Skin disease ( PSO) Infections (Fungal/ candida) Metabolic (hyperth) Environment (trauma/ UV) Drugs (tetracyclines) Tumours 4. Other Chronic renal failure/ Low albumin/ Cirrhosis Familial Arsenic Yellow Green White Purple/Black Streaks 2.Nail Colour 12
13 Purple/ Black Melanoma Haematoma Blood under nail plate Move distally with growth Painful Dermoscopy Blood spots Proximal round edge Distal linear and parallel Treatment Drain if painful Refer Haematoma Yellow Green White Purple/Black Streaks 2.Nail Colour 13
14 Streaks Longitudinal melanonychia Familial/ trauma/ drugs/ Pregnancy/ HIV/ genetic Matrix naevus Melanoma Splinter Haemorrhages Longitudinal dark red lines distal nail Damage to nail bed capillaries Causes Traumatic Psoriasis Fungal Endocarditis (SBE) SBE psoriasis 3. Nail Fold and Cuticle Cuticle Subungual hyperkeratosis Paronychia Ingrown nail 14
15 Cuticle Traumatic Biting Ragged/ Telangiectasia Connective tissue 3. Nail Fold and Cuticle Cuticle Subungual hyperkeratosis Paronychia Ingrown nail Subungual Hyperkeratosis Scale under hyponychium Psoriasis/ Fungal/ Crusted scabies 15
16 3. Nail Fold and Cuticle Cuticle Subungual hyperkeratosis Paronychia Ingrown nail Acute swollen, red, pain Staph/ strep/ HSV Minor trauma Antibiotic +/ surgery Chronic Inflamed proximal nail fold No cuticle Nail plate abnormality More than one finger 2 infection Avoid water Paronychia 3. Nail Fold and Cuticle Cuticle Subungual hyperkeratosis Paronychia Ingrown nail 16
17 Ingrown Nail Nail plate spicule into lateral nail fold Painful Improper cutting of nail Treatment Educate Remove spicule: floss/ cotton Destruction lateral matrix: chemical/ surgery Clubbing Koilonychia Others 4. Nail Shape 17
18 Clubbing Bulbous digits Congenital CHD/ CF Acquired Lung: ca lung/ PTB CVS: SBE GIT: IBD/ Liver Infection: HIV Endocrine: hyperth Clubbing Koilonychia Others 4. Nail Shape Koilonychia Nail plate thin/ flat/ spoon Normal in children Adults: iron deficiency 18
19 4. Nail Shape Clubbing Koilonychia Others Congenital malalignment Other Pachyonychia Pincer/ Trumpet Nails 5. Lesions around the nail Benign Warts Fibroma Myxoid cyst Corn/callus Malignant Melanoma SCC Bowens 19
20 Benign Wart keratolytics cryotherapy cantharidin Immunotherapy IL Bleomycin Laser Myxoid Cyst Nodule drains fluid Compresses matrix groove Melanoma SCC Bowens Malignant Bowens disease Single nail, warty changes of nail fold ooze from edge of nail Inflammation and crusting 20
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