Peer Reviewed

Photo Essay

An Atlas of Nail Disorders, Part 6

Volume 60 - Issue 4 - April 2020

AUTHORS:
Alexander K. C. Leung, MD1,2 • Benjamin Barankin, MD3 • Kin Fon Leong, MD4

AFFILIATIONS:
1University of Calgary, Calgary, Alberta, Canada
2Alberta Children’s Hospital, Calgary, Alberta, Canada
3Toronto Dermatology Centre, Toronto, Ontario, Canada
4Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

CITATION:
Leung AKC, Barankin B, Leong KF. An atlas of nail disorders, part 6. Consultant. 2020;60(4):16-18. doi:10.25270/con.2020.04.00003

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Alexander K. C. Leung, MD, 233 16th Ave NW Unit 200, Calgary, AB T2M 0H5, Canada (aleung@ucalgary.ca)

EDITOR’S NOTE:
This article is part 6 of a 15-part series of Photo Essays describing and differentiating conditions affecting the nails. Parts 7 through 15 will be published in upcoming issues of Consultant. To access previously published articles in the series, visit the Consultant archive at www.Consultant360.com and click the “Journals” tab.

Onycholysis

Onycholysis, also known as Plummer’s nail, refers to the distal or distolateral separation of the nail plate from the underlying supporting structures such as the nail bed and hyponychium.1 This is in contrast to onychomadesis, in which the separation of the nail plate from the nail bed begins proximally near the nail matrix.1 Parakeratosis of the hyponychium and distal or distolateral nail bed and desquamation of these parakeratotic cells result in loss of adherence between the nail bed and the nail plate and, eventually, onycholysis.2

Clinically, the area of onycholysis appears white due to air beneath the nail plate that has separated from the nail bed (Figure).1 The discoloration of the nail may also depend on the underlying cause. For example, yellow discoloration may result from onychomycosis. An erythematous border and splinter hemorrhages may also be present if the onycholysis is caused by psoriasis. Onycholysis is usually asymptomatic but can be painful if the condition is caused by trauma, contact irritants, psoriasis, or subungual neoplasms.3,4

Onycholysis

Trauma, including occupational trauma and sports activities, is the most common cause of onycholysis; this is especially the case for toenail onycholysis and individuals with long nails. Nail disease is seen in 40% to 50% of patients with cutaneous psoriasis, and onycholysis occurs in approximately 80% of these patients.5,6 Onychomycosis accounts for 15% to 40% of all nail diseases, and onycholysis occurs in approximately 25% of these patients.7,8 Other less common causes of onycholysis include paronychia, thyroid diseases (eg, Graves disease, hypothyroidism), diabetes mellitus, hyperhidrosis, finger sucking, contact irritants (eg, nail hardeners, cosmetic solvents), scleroderma, lichen planus, pemphigus vulgaris, Langerhans cell histiocytosis, periarticular thenar erythema with onycholysis (PATEO) syndrome, yellow nail syndrome, pellagra, β-human papillomavirus infection, hand-foot-and-mouth disease, leprosy, syphilis, multiple myeloma, medications (eg, docetaxel, paclitaxel, erlotinib, 5-fluorouracil, doxorubicin, bleomycin, capecitabine, valproic acid), drug-induced photo onycholysis (eg, psoralens, tetracyclines, fluoroquinolones, chloramphenicol, griseofulvin, oral contraceptives, olanzapine, aripiprazole), and subungual neoplasms (eg, keratoacanthoma, Bowen disease, squamous cell carcinoma, melanoma).1,3,4,9-24 Onycholysis can be idiopathic; this is a diagnosis of exclusion, in which no underlying cause can be found.

Onycholysis increases the risk of subungual infections, because separation of the nail plate from the underlying supporting structures such as the nail bed and hyponychium provides a window for pathogens to intrude the nail apparatus.6

The underlying cause should be treated if possible. It is advisable to have nails trimmed short and avoid exposure of the nails to moisture and irritants.2 Otherwise, no specific treatment is required.

REFERENCES:

  1. Jadhav VM, Mahajan PM, Mhaske CB. Nail pitting and onycholysis. Indian J Dermatol Venereol Leprol. 2009;75(6):631-633. doi:10.4103/0378-6323.57740
  2. Vélez NF, Jellinek NJ. Simple onycholysis: a diagnosis of exclusion. J Am Acad Dermatol. 2014;70(4):793-794. doi:10.1016/j.jaad.2013.09.061
  3. Frieling G, Velez N, Tahan SR, Burgin S. Isolated painful onycholysis in a 40-year-old woman with Crohn’s disease. Int J Dermatol. 2014;53(9):1127-1128. doi:10.1111/j.1365-4632.2012.05705.x
  4. Helsing P, Austad J, Talberg HJ. Onycholysis induced by nail hardener. Contact Dermatitis. 2007;57(4):280-281. doi:10.1111/j.1600-0536.2007.01121.x
  5. Schons KRR, Beber AAC, Beck MdO, Monticielo OA. Nail involvement in adult patients with plaque-type psoriasis: prevalence and clinical features. An Bras Dermatol. 2015;90(3):314-319. doi:10.1590/abd1806-4841.20153736
  6. Tan EST, Chong W-S, Tey HL. Nail psoriasis: a review. Am J Clin Dermatol. 2012;13(6):375–388. doi:10.2165/11597000-000000000-00000
  7. Ge G, Yang Z, Li D, Sybren de Hoog G, Shi D. Onychomycosis with greenish-black discolorations and recurrent onycholysis caused by Candida parapsilosis. Med Mycol Case Rep. 2019;24:48-50. doi:10.1016/j.mmcr.2019.04.005
  8. Da Silva Pontes ZBV, De Oliveira Lima E, Cavalcante Oliveira NM, Pereira Dos Santos J, Lira Ramos A, Peixoto Carvalho MFF. Onychomycosis in João Pessoa City, Brazil. Rev Argent Microbiol. 2002;34(2):95-99.
  9. Abramovici G, Keoprasom N, Winslow CY, Tosti A. Onycholysis and subungual haemorrhages in a patient with hand, foot and mouth disease. Br J Dermatol. 2014;170(3):748-749. doi:10.1111/bjd.12689
  10. Bentabet Dorbani I, Badri T, Benmously R, Fenniche S, Mokhtar I. Griseofulvin-induced photo-onycholysis. Presse Med. 2012;41(9 pt 1):879-881. doi:10.1016/j.lpm.2011.11.014
  11. Cohen O, Sharma S. Sterile matrix grafting for onycholysis in the setting of valproic acid use. JAAD Case Rep. 2015;1(6):356-358. doi:10.1016/j.jdcr.2015.07.010
  12. Gregoriou S, Karagiorga T, Stratigos A, Volonakis K, Kontochristopoulos G, Rigopoulos D. Photo-onycholysis caused by olanzapine and aripiprazole. J Clin Psychopharmacol. 2008;28(2):219-220. doi:10.1097/JCP.0b013e318166c50a
  13. Hogeling M, Howard J, Kanigsberg N, Finkelstein H. Onycholysis associated with capecitabine in patients with breast cancer. J Cutan Med Surg. 2008;12(2):93–95. doi:10.2310/7750.2008.07028
  14. Lau C-P, Hui P, Chan T-C. Docetaxel-induced nail toxicity: a case of severe onycholysis and topic review. Chin Med J (Engl). 2011;124(16):2559-2560.
  15. Leung AKC, Lam JM, Leong KF. Childhood Langerhans cell histiocytosis: a disease with many faces. World J Pediatr. 2019;15(6):536-545. doi:10.1007/s12519-019-00304-9
  16. Love TJ, Gudjonsson JE, Valdimarsson H, Gudbjornsson B. Psoriatic arthritis and onycholysis—results from the cross-sectional Reykjavik Psoriatic Arthritis Study. J Rheumatol. 2012;39(7):1441-1444. doi:10.3899/jrheum.111298
  17. Malan M, Dai Z, Jianbo W, Quan SJ. Onycholysis an early indicator of thyroid disease. Pan Afr Med J. 2019;32:31. doi:10.11604/pamj.2019.32.31.17653
  18. Rzepecki AK, Franco L, McLellan BN. PATEO syndrome: periarticular thenar erythema with onycholysis. Acta Oncol. 2018;57(7):991-992. doi:10.1080/0284186X.2017.1420912
  19. Stevenson R, El-Modir A. Unilateral onycholysis in a patient taking erlotinib (Tarceva). BMJ Case Rep. 2011;2011:bcr0420114157. doi:10.1136/bcr.04.2011.4157
  20. Takasu N, Seki H. Plummer’s nails (onycholysis) in a thyroid-stimulation-blocking antibody (TSBAb)-positive patient with hypothyroidism. Intern Med. 2018;57(20):3055-3056. doi:10.2169/internalmedicine.0809-18
  21. Umanoff N, Werner B, Rady PL, Tyring S, Carlson JA. Persistent toenail onycholysis associated with beta-papillomavirus infection of the nail bed. Am J Dermatopathol. 2015;37(4):329-333. doi:10.1097/DAD.0000000000000110
  22. Vassallo C, Derlino F, Torti S, et al. Longitudinal deep fissure and distal onycholysis of the right thumb—quiz case. Arch Dermatol. 2012;148(8):947-952. doi:10.1001/archdermatol.2012.1350
  23. Wu E, Viegas SF. Finger sucking and onycholysis in an infant. J Hand Surg Am. 2005;30(3):620-622. doi:10.1016/j.jhsa.2004.11.002
  24. Zaias N, Escovar SX, Zaiac MN. Finger and toenail onycholysis. J Eur Acad Dermatol Venereol. 2015;29(5):848-853. doi:10.1111/jdv.12862

Onychauxis

Onychauxis refers to abnormal thickening of one or more fingernails and/or toenails. The condition is characterized by hyperkeratosis, discoloration, and loss of translucency of the nail plate, with or without subungual hyperkeratosis (Figure).1,2 Affected nails have a white or yellow appearance. If left untreated, the nail may turn red or black. Onychauxis is more commonly seen in elderly individuals than in children and young adults. The condition is usually asymptomatic but at times may be painful.

Onychauxis

Onychauxis can be congenital or acquired. Congenital onychauxis can be caused by missense mutations in the frizzled class receptor 6 gene (FZD6) mapped on 8q22.3, encoding membrane-bound Wnt receptor protein.3,4 The condition is inherited as an autosomal recessive trait.3,4

Mechanical trauma to the nail is an important acquired cause of onychauxis. Individuals who inflict a lot of pressure on the feet for prolonged periods of time, such as dancers, athletes, and those with faulty biomechanics (eg, hallux valgus, overlapping/underlapping toes, foot-to-shoe incompatibility) are particularly susceptible to develop onychauxis.1,2 Other acquired causes of onychauxis include psoriasis, onychomycosis, diabetes mellitus, acromegaly, congenital syphilis, Darier disease, Sézary syndrome, pityriasis rubra pilaris, and poor circulation.5-7 Onychauxis can also be idiopathic, especially in the elderly age group.1

The condition can be cosmetically unsightly and socially embarrassing, especially if the onychauxis is present on the fingernails. Other complications include pain, onycholysis, and increased susceptibility to onychomycosis.1

The underlying condition should be treated if possible. Mild and asymptomatic case may not have to be treated. Periodic partial or total debridement of the thickened nail plate may be considered if the condition is associated with complications or significant morbidity.

REFERENCES:

  1. Cohen PR, Scher RK. Geriatric nail disorders: diagnosis and treatment. J Am Acad Dermatol. 1992;26(4):521-531. doi:10.1016/0190-9622(92)70075-q
  2. Singh G, Haneef NS, Uday A. Nail changes and disorders among the elderly. Indian J Dermatol Venereol Leprol. 2005;71(6):386-392. doi:10.4103/0378-6323.18941
  3. Fröjmark A-S, Schuster J, Sobol M, et al. Mutations in frizzled 6 cause isolated autosomal-recessive nail dysplasia. Am J Hum Genet. 2011;88(6):852-860. doi:10.1016/j.ajhg.2011.05.013
  4. Raza SI, Muhammad N, Khan S, Ahmad W. A novel missense mutation in the gene FZD6 underlies autosomal recessive nail dysplasia. Br J Dermatol. 2013;168(2):422-425. doi:10.1111/j.1365-2133.2012.11203.x
  5. Damasco FM, Geskin LJ, Akilov OE. Nail changes in Sézary syndrome: a single-center study and review of the literature. J Cutan Med Surg. 2019;23(4):380-387. doi:10.1177/1203475419839937
  6. Dogiparthi SN, Muralidhar K, Seshadri KG, Rangarajan S. Cutaneous manifestations of diabetic peripheral neuropathy. Dermatoendocrinol. 2017;9(1):e1395537. doi:10.1080/19381980.2017.1395537
  7. Leung AKC, Leong KF, Lam JM. A Case of congenital syphilis presenting with unusual skin eruptions. Case Rep Pediatr. 2018;2018:1761454. doi:10.1155/2018/1761454

Onychogryphosis

Onychogryphosis is a disorder of nail plate growth characterized by an opaque, yellowish brown, hyperkeratotic nail plate that is distorted, grossly thickened, elongated, spiraled, and partially curved (Figure).1 The condition can be oyster-like or resemble a ram’s horn, hence the condition is also called ram’s horn nail.2,3

Onychogryphosis

The nail of the great toe is particularly vulnerable, but other toenails can also be affected.3,4 In onychogryphosis, the nail plate typically grows upward and thereafter deviates towards the other toes.1 The nail plate grows hypertrophied and unevenly at the nail matrix.1 The direction and amount of curvature of the nail is determined by whether the medial or lateral side of the germinal matrix grows more rapidly.

Onychogryphosis can be congenital or acquired. Congenital onychogryphosis is rare and is inherited as an autosomal dominant trait with variable expression.1,5 The onset is usually within the first year of life. All the fingernails and toenails may be affected. In infants and young children, onychogryphosis can be accompanied by congenital malalignment of the great toenail.2,5 Syndromes associated with onychogryphosis include Haim-Munk syndrome, ichthyosis hystrix, Papillon-Lefèvre syndrome, and ectodermal dysplasia-syndactyly syndrome type 1.5-8

Acquired onychogryphosis is most commonly observed in elderly individuals, especially in those who are homeless and those fail to perform adequate foot and nail care.1,2,8 Other causes of onychogryphosis include recurrent trauma, burns, continuous pressure and friction from improper footwear, bony deformities (eg, hallux valgus, hammer toes, overlapping digits), psoriasis, onychomycosis, ichthyosis, syphilis, pemphigus, tuberous sclerosis complex, poor peripheral circulation, diabetes mellitus, and hyperuricemia.1-5,9-12 Onychogryphosis can also be idiopathic and is an isolated finding.

Complications can include pain, distal onycholysis, ingrown toenails, paronychia, onychomycosis, subungual hemorrhage, and inability to wear proper footwear.1,13 Rarely, the condition can be complicated by subungual gangrene due to pressure effects, especially in those individuals with peripheral vascular disease or diabetes mellitus.3

The underlying cause should be treated if possible. Conservative measures include blunt dissection of the thickened nail plate using a nail clipper or a dual-action nail nipper after chemical avulsion with 50% potassium iodine or 40% urea under occlusion.1 Avulsion of the nail plate followed by matricectomy can be considered for the symptomatic patient in whom the conservative measures fail.1,5

REFERENCES:

  1. Ko D, Lipner SR. Onychogryphosis: case report and review of the literature. Skin Appendage Disord. 2018;4(4):326-330. doi:10.1159/000485854
  2. Chang P, Meaux T. Onychogryphosis: a report of ten cases. Skinmed. 2015;13(5):355-359.
  3. Singh G, Haneef NS, Uday A. Nail changes and disorders among the elderly. Indian J Dermatol Venereol Leprol. 2005;71(6):386-392. doi:10.4103/0378-6323.18941
  4. Freiberg A, Dougherty S. A review of management of ingrown toenails and onychogryphosis. Can Fam Physician. 1988;34:2675-2681.
  5. Gürbüz K, Ozan F, Kayali C, Altay T. Total matricectomy and V-Y advancement flap technique in the treatment of onychogryphosis. Dermatol Surg. 2017;43(4):583-586. doi:10.1097/DSS.0000000000001013
  6. Biswas P, De A, Sendur S, Nag F, Saha A, Chatterjee G. A case of ichthyosis hystrix: unusual manifestation of this rare disease. Indian J Dermatol. 2014;59(1):82-84. doi:10.4103/0019-5154.123512
  7. Hattab FN, Amin WM. Papillon-Lefèvre syndrome with albinism: a review of the literature and report of 2 brothers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100(6):709-716. doi:10.1016/j.tripleo.2004.08.030
  8. Mohammad A. Unusual manifestations of ectodermal dysplasia-syndactyly syndrome type I in two Yemeni siblings. Dermatol Online J. 2015;21(1):13030/qt7cz9v3m0.
  9. Bernard O. Onychogryphosis and the involuted nail in diabetes mellitus. West Indian Med J. 2001;50(suppl 1):29-30.
  10. Han X-c, Zheng L-q, Zheng T-g. Onychogryphosis in tuberous sclerosis complex: an unusual feature. An Bras Dermatol. 2016;91(5 suppl 1):116-118. doi:10.1590/abd1806-4841.20164720
  11. Oka H, Asakage Y, Inagawa K, Moriguchi T, Hamasaki T. Free vascularized nail grafts for onychogryphosis of bilateral thumbnails after burn injury. Burns. 2002;28(3):273-275. doi:10.1016/s0305-4179(01)00121-8
  12. Möhrenschlager M, Wicke-Wittenius K, Brockow K, Bruckbauer H, Ring J. Onychogryphosis in elderly persons: an indicator of long-standing poor nursing care? Report of one case and review of the literature. Cutis. 2001;68(3):233-235.
  13. Maddy AJ, Tosti A. Hair and nail diseases in the mature patient. Clin Dermatol. 2018;36(2):159-166. doi:10.1016/j.clindermatol.2017.10.007