HMCL312. Session 8 Nail signs.

Transcription

1 HMCL312 Session 8 Nail signs

2 SN08 Overview Nutrient deficiency and disease associated Nail Diagnosis Pre-Assessment Considerations: o Working hypothesis of the pattern of disturbance o Differential diagnoses o Duty of care o Medical Red Flags - referral Endeavour College of Natural Health 2

3 Nail assessment In the clinical setting, the nails provides a quick, easily accessible and noninvasive means of assessment. In the context of Objective data, nails can indicate overall health of the client and guide towards further questioning and investigations. In general they give information about: o Dietary intake o Digestive absorption o Blood flow o Nutritive value of the blood Endeavour College of Natural Health 3

4 Common Causes of Nail Abnormalities o Abnormalities in the colour, shape, texture, size or thickness of the nails are often the result of either injury, infection, disease, poisoning, nutritional deficiency or genetic pre-disposition, and can provide many clues as to underlying systemic disease long before other symptoms arise nailmag.com Endeavour College of Natural Health 4

5 Nail Diagnosis Endeavour College of Natural Health 5

6 Sign Splitting, fraying, chipping, peeling, easily broken Thinning and Softening Horizontal Grooving or Ridging Vertical Grooving or Ridging Brittleness Common Nail Signs Deficiency Vitamin A, C, D, calcium, protein intake and absorption, poor diet and malnutrition. Vitamin C, B12, protein intake and absorption, poor diet and malnutrition. Protein intake and absorption, poor diet and malnutrition. Vitamin A, calcium, iron, silica, protein intake and absorption. Iron Spooning/koilonychia Iron deficiency (Mahan and Escott-Stump, 2008) Endeavour College of Natural Health 6

7 Nutritional Deficiency Endeavour College of Natural Health 7

8 Splitting Vitamin A, C, D, calcium, protein intake and absorption, poor diet and malnutrition. Just.health.com Endeavour College of Natural Health 8

9 Thinning & Softening o Vitamin C, B12, protein intake and absorption, poor diet and malnutrition. postitvmed.com Endeavour College of Natural Health 9

10 Horizontal Grooving or Ridging o Protein intake and absorption, poor diet and malnutrition. Also signs of a systemic illness or trauma (Beaus Ridges.) Endeavour College of Natural Health 10

11 Transverse Depressions (Beau s Ridges) o Interruption in protein formation and nail growth which often follows local trauma about one month after the event o Can occur after illness, or major metabolic condition o May reflect poor nutritional status, febrile illness, or a reaction to medication, Chemotherapy or other damaging event o May indicate malnutrition o Exposure to cold temperatures in patients with Raynaud's disease Endeavour College of Natural Health 11

12 Vertical Grooving or Ridging buzzle.com o Vitamin A, calcium, iron, silica, protein intake and absorption. handresearch.com Endeavour College of Natural Health 12

13 Vertical striations o Alopecia areata, vitiligo, atopic dermatitis, psoriasis, splinter haemorrhage o Subacute bacterial endocarditis o SLE o Rheumatoid arthritis o Antiphospholipid syndrome o Peptic ulcer disease o Malignancies o Oral contraceptive pill o Pregnancy o Ageing Endeavour College of Natural Health 13

14 Vertical (Longitudinal) Ridging o Poor absorption of EFA's, Vitamins and Minerals (Iron, Silica); Thyroid dysfunction; Kidney failure o May indicate a tendency to arthritis o Occur in some patients with rheumatoid arthritis, peripheral vascular disease, lichen planus, or Darier's disease o Longitudinal red/white striations invariably occur with Darier's disease, and V-shaped notching or nicking of the free edges of the nails are also common Endeavour College of Natural Health 14

15 Darier's Disease o V-shaped nicking and red/white longitudinal striations of Darier's disease Endeavour College of Natural Health 15

16 Brittleness handresearch.com Endeavour College of Natural Health 16

17 Koilonychia o Koilonychia is associated with chronic iron deficiency anaemia It has even been reported in haemo- chromatosis. o It can be a normal finding in infants and resolves within the first months of life. handresearch.com Endeavour College of Natural Health 17

18 Spooning or Concavity o Associated with iron-deficiency anaemia and Plummer-Vinson syndrome, as a result of thinning and softening of the nail plate o Spoon-shaped nails are a normal, physiologic occurrence in children and tend to resolve, either with treatment or with ageing o Indicate deficiency of iron, protein (especially sulphur containing amino acids) o Possible precursor to haemochromatosis o Raynaud's disease; SLE Endeavour College of Natural Health 18

19 Spooning or Concavity Endeavour College of Natural Health 19

20 Brief case scenario: o A client presents with digestive problems (cramping and bloating after meals) and a largely takeaway vegetarian based diet. Additionally she has heavy menstrual bleeding and has been feeling very fatigued for several months. o What appearance would you expect her nails to have? What deficiency is it most likely indicative of? How long might she have had this deficiency? Endeavour College of Natural Health 20

21 Pitting (punctate depressions) o Punctate depressions in the nail plate, sometimes with yellow or brown oil spots o The pits represent abnormal keratinisation in the nail matrix o Indication of connective tissue disorders o Most commonly occurs with psoriasis, less so with alopecia areata and eczema o Reiter's syndrome o Sarcoidosis o Pemphigus o Alopecia areata (Fawcett et al, 2004) Endeavour College of Natural Health 21

22 Pitting (punctate depressions) Endeavour College of Natural Health 22

23 Brief case scenario: A 75 year old client presents with long term reflux and arthritis that she manages with pain killers, the most recent of which is Panadol-Osteo which she finds helpful. On review, her diet is very refined and deficient of many nutrients, especially essential fatty acids. What would you anticipate her nails might be like? What kind of nail signs? What nutrients or dietary changes would you suggest to improve her nails (and her overall health)? Endeavour College of Natural Health 23

24 Nail signs indicative of Nutritional Deficiency Sign White Spots Paleness or whitening Yellowing Darkening or blackening Pitted red-brown spot Deficiency Vitamin A, calcium, zinc (Bakan, 1990) Iron, B12, Folic Acid, protein intake and absorption. Vitamin E Vitamin B12 Vitamin C Endeavour College of Natural Health 24

25 White Spots nailsmag.com o Vitamin A, o calcium, zinc o (Bakan 1990) examiner.com Endeavour College of Natural Health 25

26 Paleness or whitening o Iron, B12, Folic Acid, protein intake and absorption. Endeavour College of Natural Health 26

27 o White, Crumbly and Soft o May be fungal infection White Nail o White with red at the tips o Cirrhosis of the liver; o Kidney disorders o Anaemia o Fungal infection Endeavour College of Natural Health 27

28 White Nail o Unusual whitening of the nail plate where the lunula may be obliterated, may result from: o Liver disease (Cirrhosis). o Kidney dysfunction o Diabetes mellitus o Heart Disease o Hyperthyroidism o Anaemia o Arsenic poisoning o Renal failure o Pneumonia o Hypo-albuminaemia Malnutrition Endeavour College of Natural Health 28

29 Muehrcke's Lines (pairs of transverse white lines) o Interruption of pigmentation (Specific for hypoalbuminaemia) o May disappear when protein levels normalise o May also indicate Kidney disease o Liver disease o Malnutrition o Chemotherapy (Fawcett et al, 2004) Endeavour College of Natural Health 29

30 Mees' lines (Aldrich-Mees' lines) o Single transverse white line o Heavy metal poisoning o Sign of interrupted metabolic activity; o Hodgkin's disease o Congestive Heart Failure o Malaria o Chemotherapy o Carbon monoxide poisoning o Renal failure. (Fawcett et al, 2004) Endeavour College of Natural Health 30

31 o Usually associated with Lymphedema & Respiratory tract disorders (Tosti & Piraccini, 2000) o Pulmonary disorders (e.g. Bronchiectasis, Tuberculosis, Pleural Effusion) o Lymphatic dysfunction (Lymphoedema, especially of the ankles) o Rheumatoid arthritis o Renal disease (Nephrotic syndrome) Yellowing Endeavour College of Natural Health 31

32 Yellowing o Immuno-deficiency o Vitamin E deficiency o Thyroiditis o Raynaud's disease o Liver dysfunction o Fungal infection o Psoriasis Endeavour College of Natural Health 32

33 Yellow Tips o Liver problems o Melanoma o Digestive disturbances o Smoker o Tetracycline. o Rx = Oral Vitamin E at doses IU daily for 6-12mths may induce complete clearing of nail changes (Tosti & Piraccini, 2000) Endeavour College of Natural Health 33

34 Green o Pseudomonas o Candidiasis o Bacillus infection o Localized fungal infection o Allergies to cleaning agent o Serious emphysema Endeavour College of Natural Health 34

35 Pitted red-brown spot o Pitted red-brown spots o May indicate psoriasis o Deficiency of folic acid, protein and/or Vitamin C Endeavour College of Natural Health 35

36 Red Nail o Red Bands at the Tips(Terry s Nails) o Liver disease o Renal disease o Redness of the lunula o Excess of RBC o Heart disease o Collagen vascular disease o Haematological malignancy o Tetracycline therapy

37 Grey o Arthritis o Oedema o Malnutrition o Post-operative effects o Glaucoma o Cardio-pulmonary disease Endeavour College of Natural Health 37

38 Blue or Blue-Grey Nails o Blue or Deep Blue: o Indicates poor oxygenation of the blood o Lupus erythematosus/ RA o Liver disease (Hepatitis) o Kidney disease o Copper or silver poisoning o Anaemia (Decreased haemoglobin) o Increased inflammation o Cholesterol Fawcett et al, 2004) Endeavour College of Natural Health 38

39 Blue, Purple, Black Nails o Blue, Purple & Black o Usually due to trauma o May be a sign of vitamin B12 deficiency o Oxygen deprivation o Circulatory problems o Congenital disorder o Blue or azure lunula o May indicate Wilson s Disease (Hepatolenticular degeneration) o Quinacrine therapy o Pulmonary disease o Silver poisoning Endeavour College of Natural Health 39

40 o Browning Darkening Brown o Excessive fluoride ingestion; Arsenic or copper poisoning; Fungal infection o Brown discoloration that has spread to the surrounding tissue could indicate gastro-intestinal polyps or malignant melanoma o Pitted brown spots or splits fingernail tips o May indicate psoriasis o Brown Spots are typically a sign of infection (Fungal) o Dark nails that are flat and/or thin o Indicate vitamin B(12) deficiency o Dark pigment on distal nail:drug-induced (Phenothiazines) Endeavour College of Natural Health 40

41 Darkening or blackening o Vitamin B12 schaltzie-speaks.hubpages.com Endeavour College of Natural Health 41

42 Darkening Black o Blackening or Darkening o Excessive fluoride ingestion o Heavy metal poisoning (Silver) o Anaemia o B-12 deficiency o Bacterial infection o Kidney disease o Adrenal gland problems o Liver disease o Cancer or melanoma o Trauma Endeavour College of Natural Health 42

43 Darkening Black o Black Spots o Typically a sign of infection o Any black discolouration that has spread to the surrounding tissue could indicate gastro-intestinal polyps or malignant melanoma Endeavour College of Natural Health 43

44 Longitudinal Melanonychia o Black discoloration of the proximal nail fold at the base of the pigmented streak (Hutchinson's sign) is a sign for melanoma o Longitudinal melanonychia in one nail without an obvious explanation warrants a biopsy of the nail matrix. Melanoma of the nail unit has a poor prognosis Endeavour College of Natural Health 44

45 Half White & Half Brown Nails o Renal disease o Increased melanin production (Fawcett et al, 2004) Endeavour College of Natural Health 45

46 Onychomycosis (Tinea unguium) o A fungal or yeast infection of the nail, usually caused by Tinea rubrum, T. mentagrophytes, or Candida albicans; o Most common nail disorder! o Predisposing factors for infection include immune problems, heat, moisture, trauma, diabetes mellitus, and tinea pedis o Affected nails are dystrophic and hyperkeratotic (thickened), often with yellow-brown discoloration Endeavour College of Natural Health 46

47 Onychomycosis (Tinea unguium) o Treatment can be symptomatic, frequently with the aid of a podiatrist for toenail onychomycosis. If warranted, systemic treatment involves the use of either terbinafine or itraconazole (Success with either agent is less than 50%, and recurrences are common) SOURCE: CDC/Dr. Edwin P. Ewing, Jr. Endeavour College of Natural Health 47

48 Nail Plate Separation (Onycholysis) o It can be caused by any local problem, such as periungual warts or onychomycosis o In patients with hyperthyroidism, onycholysis is known as Plummer's nails o Hyperthyroidism also can cause brown discoloration of the nail plate o Psoriasis o In the absence of trauma or psoriasis, onycholysis should prompt a search for symptoms of hyperthyroidism o Anaemia Endeavour College of Natural Health 48

49 Nail Plate Separation (Onycholysis) o Fungal, Yeast or Bacterial Infections o Medications, Drugs (e.g. Tetracycline) o Chemotherapy o Raynaud s disease o SLE o Thyrotoxicosis o Hyperthyroidism o Amyloidosis o Sarcoidosis and other connective tissue disorders Endeavour College of Natural Health 49

50 Nail Plate Separation o Onycholysis may accompany psoriasis, when the distal portion of the nail matrix is affected Endeavour College of Natural Health 50

51 Psoriasis o Characterised by raw, scaly skin and is sometimes confused with eczema o When it attacks the nail plate, it will leave it pitted, dry, and it will often crumble. The plate may separate from the nail bed and may also appear red, orange or brown, with red spots in the lunula Endeavour College of Natural Health 51

52 Thickened Nails o Unusually thick nails: may be the result of internal disorders o May indicate a weakening of the vascular system, with circulatory problems o Fungal infections o Heredity o Mild, persistent trauma to the nail Endeavour College of Natural Health 52

53 Nail Hematoma o The result of trauma to the nail plate, such as trapping your finger in the car door or hitting the fingernail with a hammer Endeavour College of Natural Health 53

54 Pterygium of Nail o An inward advance of skin over the nail plate o Usually the result of trauma to the matrix due to a surgical procedure, or by a deep cut to the nail plate o Pterygium results in the loss of the nail plate due to the development of scar tissue Endeavour College of Natural Health 54

55 In-grown Toenail (Onychogryposis) o Claw-type nails, characterised by a thickened nail plate and often the result of trauma o Often require surgical intervention to relieve the pain Endeavour College of Natural Health 55

56 Clubbing o Clubbing is one example of a nail manifestation of systemic disease and was first described by Hippocrates in the fifth century B.C., and may indicate o Pulmonary Disease, including Bronchiectasis, Bronchitis, Lung abscess, Empyema, Pulmonary Fibrosis, Cystic Fibrosis, Asbestosis, Malignancy o Cirrhosis of the Liver o Cardiac Disease, such as Congenital Heart Disease, Endocarditis, Atrioventricular malformations, Fistulas o GIT Diseases, such as: Coeliac Disease, Ulcerative Colitis or Inflammatory Bowel Disease o Hyperthyroidism Endeavour College of Natural Health 56

57 Clubbing o The finding of clubbing without obvious associated disease should prompt a search for bronchial or cardiac disease Endeavour College of Natural Health 57

58 Splinter Haemorrhage o This sign often follows trauma to the nail o If no trauma, look for bacterial endocarditis o They may resolve, recur, or persist (Fawcett et al, 2004) o Possible indication of vitamin C deficiency Endeavour College of Natural Health 58

59 Verruca Vulgaris (Warts) o Warts, or verruca vulgaris, are an infection of the proximal and lateral nail folds o The human papilloma virus (HPV), types 1, 2, and 4 are primarily responsible o Because of the location, these warts are particularly difficult to treat, especially if they extend subungually o Subungual warts may cause deformity or discoloration of the nail plate o Affected patients are often nail biters Endeavour College of Natural Health 59

60 Paronychia Infection o Can be caused by a number of bacteria, fungi, yeast and viruses o Usually staphylococcus, streptococcus or candidiasis infection Endeavour College of Natural Health 60

61 Acute Paronychia o Inflammation of the proximal and lateral nail folds characterised by erythema, oedema, and pain o Purulent drainage with compression behind the cuticle may also occur o Trauma is often the initial event with secondary infection with Staphylococcus aureus or Streptococcus pyogenes o Treatment usually requires compresses and an oral anti-staphylococcal antibiotic Endeavour College of Natural Health 61

62 Chronic Paronychia o Usually a non-infectious disease that follows irritant or allergic contact dermatitis of the proximal nail fold o The cuticle is invariably absent o Affected individuals often trim the cuticles aggressively, or do wet work with their hands o Secondary infection with Candida albicans is common o Treatment involves aeration, and a topical and/or oral antifungal agent Endeavour College of Natural Health 62

63 Tinea Unguis (Ringworm of the nails) o Fungal infection, characterised by nail thickening, deformity, and eventually results in nail plate loss. Endeavour College of Natural Health 63

64 Squamous Cell Carcinoma (SCC) o The most common malignancy of the nail unit o SCC is usually a verrucal (warty) plaque on the lateral nail fold of the finger, and may resemble a wart unresponsive to traditional therapy o SCC is associated with HPV-16 infection and less so with trauma and radiation o SCC of the nail unit grows slowly and metastasis is rare Endeavour College of Natural Health 64

65 Melanonychia (vertical pigmented bands) o Described as nail 'moles' which usually form in the nail matrix o Could signify malignant melanoma or lesion Endeavour College of Natural Health 65

66 Other Nail Considerations o Over-Sized Moons: o Overactive thyroid; o Genetics; o Self-induced trauma o No Moons: o Under-active thyroid; o Genetics. Endeavour College of Natural Health 66

67 Pre-assessment Considerations Having gathered information about the patient (both subjective & objective) the next step in the Naturopathic consultation process involves analysing the various information and putting into some form of perspective Considerations prior to formulating an assessment of the patient should include: Working hypothesis of the pattern of disturbance Differential diagnosis Rule-ins/rule-outs Medical Red Flags need for referral? Duty of care/scope of practice Endeavour College of Natural Health endeavour.edu.au 67

68 Pattern of Disturbance Via the process of gathering patient information the Naturopath begins to formulate an impression of what is going on with the patient (their pattern of disturbance). This impression is formed from information relating to the physical, mental/psychological, emotional & spiritual aspects of the patient and their health condition. Where a biomedical practitioner aims to identify/diagnose a disease entity so that the specific pathophysiology can be determined and treated, the Naturopath looks to understand: the pattern of disturbance; the disturbing factors/obstacles to cure; the process of disease/health (is the condition acute/subacute/chronic/degenerative). Endeavour College of Natural Health endeavour.edu.au 68

69 Analysing the Pattern of Disturbance Is there a central theme or a weak link in the patient s life that has led to their current condition of health? What are the contributing or disturbing factors to the patient s condition? At this present time, what are the driving factors in the patient s health condition? What tissues, organs, systems are affected? What degenerative processes are at play currently? What regenerative processes are at play currently? Endeavour College of Natural Health endeavour.edu.au 69

70 The Mind Map and the Timeline of Health are useful tools for assisting to formulate an impression of the patient s pattern of disturbance Endeavour College of Natural Health endeavour.edu.au 70

71 Tutorial Review the Tutorial Case provided, develop a mind map and treatment strategy for the case. Consider prioritising treatment, differential diagnosis, further investigations needed, long and short term goals and treatment plan options. Apply holistic principles to your case understanding. If time allows look at the other case studies and apply the same considerations Handout Cases 1, 2, 3, 4 Endeavour College of Natural Health 71

72 Tutorial Tongue and nail assessment on a partner 1. Chose a partner and conduct a Nail and Tongue assessment. 2. Explain Nail and Tongue assessment to your partner and let them know what you plan to do. 3. In easy to understand terms describe to your partner your findings. Imagine that they are a first appointment client. 4. Now allow your partner to give you feedback on your Nail and Tongue assessment skills and also how they felt with your explanation and account of your findings on their tongue and nail appearance. Endeavour College of Natural Health 72

73 Bibliography 1. Yale, S. and La Valle, J.B. (2002). Food Allergies and Atopic Dermatitis. Alternative & Complementary Therapies. 2. Sebrell, W. H. (1945). Deficiency Diseases in General Practice. Southern Medical Journal, 39 (3), pp: Poole, W. L. (1957). Effect of Vitamin B Complex and S-Factor on Acne Rosacea. Southern Medical Journal, 50 (2), pp: Majamaa, H., Miettinen, A., Laine, S., Isolauri, E. (1995) Intestinal inflammation in children with atopic eczema: faecal eosinophil cationic protein and tumour necrosis factor-a as non-invasive indicators of food allergy. Clinical & Experimental Allergy, 26 (2), pp: Proksch, E., Folster-Holst, R., Jensen, J. M. (2006) Skin barrier function, epidermal proliferation and differentiation in eczema. Journal of Dermatological Science, 43 pp: Heath, ML., Sidbury, R. (2006) Cutaneous manifestations of nutritional deficiency, Current Opinion in Pediatrics, Vol 18 (4), pp: Fawcett, R. S., Linford, S., Stulberg, D. L. (2004) Nail abnormalities: clues to systemic disease, American Family Physician, 69 (6) pp: Tosti, A., Piraccini, B. M. (2000). Treatment of Common Nail Disorders, Dermatologic Clinics. 18 (2) 9. Field, A. E., Speechley, J. A., Rugman F. R., Varga, E., Tyldesley, WR. (1995). Oral signs and symptoms in patients with undiagnosed vitamin B12 deficiency, Journal of Oral Pathology and Medicine, 24, p: Marks, R and Simons, M. J. (1979). Geographic tongue a manifestation of atopy. British Journal of Dermatology, 101, pp: Rogers, RS and Bruce, A. J. (2004). The tongue in clinical diagnosis, European Academy of dermatology and Venerology, 18, pp: Endeavour College of Natural Health 73

74 Bibliography 12. Jansen, A.J. and Bailey, K.V. (1977). The early detection of childhood malnutrition in the south pacific, J Trop Pediatr, Vol 23, pp: Femiano, F. (2001). Geographic tongue (migrant glossitis) and psoriasis, Minerva Stomatol, Vol 50 (6) pp: Smith, C and Song, W. (1996). Comparative nutrition of pantothenic acid, The Journal of Nutritional Biochemistry, Vol 7 (6), pp: Areekul, S., Panatampon, P. and Doungbarn, J. (1977.) Vitamin B12 and vitamin B12 binding proteins in liver diseases, Southeast Asian J Trop Med Public Health, Vol 8 (3) pp: Barthelemy, H., Chouvet, B., Cambazard, F. (1986) Skin and mucosal manifestations in vitamin deficiency, J Am Acad Dermatology, Vol 15 (6) pp: Predniville, J.S and Manfredi, L.N. (1992). Skin signs of nutritional disorders, Seminars in Dermatology, 11 (1) pp: JAE-YOUNG UM et al. (2004). Association Between Iris Constitution and Apolipoprotein E Gene Polymorphism in Hypertensives, The Journal of Alternative and complementary medicine, 10 (6) pp: Taher, Q et al (2004) Nutritional Kiolonychia in 32 Iraqi subjects, Annual Saudi Medicine, Vol 25 (2) pp: just.health.com Tully, A.S, Trayes, K.P, Studdiford, J. (2012). American Family Physician, Evaluation of nail abnormalities. 85(8): Endeavour College of Natural Health 74

75 COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been reproduced and communicated to you by or on behalf of the Australian College of Natural Medicine Pty Ltd (ACNM) trading as Endeavour College of Natural Health, FIAFitnation, College of Natural Beauty, Wellnation - Pursuant Part VB of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Endeavour College of Natural Health 75