ALTERATIONS IN THE NAIL PLATE

DR. YUGANDAR

KOILONYCHIA

Reverse curvature in longitudinal & Transverse axes giving a concave dorsal aspects of nail

Signs most prominent in great toe & thumb

Iron def anemia in adults Common feature in infancy great toe

nail,persistence indicative of deficiency of cysteine rich keratin in Trichothiodystrophy

KOILONYCHIA

-Spoon shaped deformity

-Normal Convexity replaced byCentral Concavity

-Surrounded by Distal & Lateral Margins

-Lichenplanus,hypothyroidism,hemochromatosis,20- nail dystrophy

KOILONYCHIA(SPOON NAIL)

BEAUS LINES

Single horizontal ridge by horizontal lines of darkened cells and linear depressions

It is the result of any interruption in the protein formation of the nail plate

trauma, illness, malnutrition or any major metabolic condition, chemotherapy

BEAU’S LINES

Multiple transverse ridging

Chemotheraphy with Breast Cancer

Beau’s line; Zinc deficiency

BEAU’S LINES

TRACHYONYCHIA (20-NAIL DYSTROPHY,SANDPAPERED NAILS)

Rough surface affecting all nail plates,idiopathic forms k/s 20 nail dystrophy

k/a Sand Blasted Nails in French means grey,roughened surface

Alopecia areata, Psoriasis,Lichen planus

Histology shows spongiosis & lymphocytic infiltrate

ONYCHOMADESIS(NAIL SHEDDING) Detachment of the

nail plate from proximal nail fold,d/t severe insult that produces arrest of nail matrix activity

Proximal detachment of nail

Most often traumatic

ONYCHAUXIS

GREAT TOE NAILS GROSSLY THICKENED WITH TRANSVERSE RIDGING ( ONYCHAUXIS )

Nail thickening d/t subungual scales

Subungual hyperkeratosis

psoriasis,onychomycosis,eczema

ONYCHIA

• Inflammation of the nail matrix

• It is accompanied by pus formation

• There is Inflammation within the nail plate

ONYCHOCRYPTOSIS (INGROWN TOE NAIL) Lateral ingrowing usually affects hallux,

great toe Teenagers,Young adults,congenital

malalignment of big toes nails often present

Ppt by improper nail cutting and hyperhidrosis

Growth of granulation tissue undergoes epithelialization

DD: Multiple Periungual Pyogenic granulomas d/t retinoids,ART drugs

ONYCHOCRYPTOSIS :TREATMENT

Prevention through patient education Removal of embeded spicule Uplifting of lateral nail plate Chemical – 80% Phenol,Laser or

Surgical removal of Lateral Matrix in severe cases

Granulation tissue prevented by topical antibiotics & steroids,

ONYCHOCRYPTOSIS(INGROWN NAILS)

Also known as ingrown nails

May affect either the fingers or toes

The nail grows into the sides of the flesh & may cause infection

WASHBOARD NAILS

HABIT TIC DEFORMITY

Dystrophic nails Transverse ridging Absent of cuticle Excoriation of

Proximal nail fold

ONYCHORRHEXIS

Brittle nails,split vertically, peel or have

vertical ridges.

The result of heredity, the use of strong

solvents in the workplace or the home,

including household cleaning solutions. 

Lichen Planus,tumours which

compromise vascular supply

ONYCHORRHEXIS

Thinning of Nail plate

Longitudinal ridging & fissuring

Mild Longitudinal ridging is characteristic of Ageing

ONYCHOGRYPOSIS

Claw-type nails that are characterized by a thickened nail plate

Often the result of trauma

This type of nail plate will curve inward, pinching the nail bed and sometimes require surgical intervention to relieve the pain.

ONYCHATROPHIA

It is an atrophy or wasting away of the nail plate

which causes it to lose its luster, become smaller & sometimes shed entirely

Injury or disease may account for this irregularity

PINCER NAILS

Painful abnormality of nails Toe >> finger nails a/w subungual exostosis Distal nail plate over curved &

compresses subungual tissue

BRITTLE NAILS a vertical splitting or

separation of the nail plate layers at the distal (free) edge of the nail plate

characteristic of the natural aging process.

overexposure to water and chemical solvents such as household cleaning solutions

Brittle nail

PACHYONYCHIA CONGENITA

AD,very rare Hypertrophy of nails occurs a/w nail bed

hyperkeratosis PC 1: Normal by birth,Progressively

discoloured,thicken more on hands,Palmo-plantar hyperkeratosis & warty lesions at knee,elbows,buttocks,Defect Keratins 6a & 16

PC 2: Less severe nail thickening & Keratosis, a/w hamartomas,Kinky scalp hair,epidermal cysts,Defect keratins 6b & 17

PACHYONYCHIA CONGENITA

ALTERATIONS IN NAIL SIZE

ANONYCHIAABSENCE OF ALL OR PART OF ONE OR SEVERAL NAILS

Congenital:Mutation in R-

Spondin 4 gene

Transient :Due to nail shedding

Acquired:Due to scarring of nail

matrixTrauma,Burns,Surgery,Lichenplanus.Epidermolysis bullosa-

irreversible nail loss

ANONYCHIA

It is a/w DOOR syndrome,AEC syndrome,EEC syndrome,TOOD syndrome

Anonychia atrophica : it is an acquired nail dystrophy,Permanent,secondary to nail matrix damage

ANONYCHIA

Congenital absence of nails in child

MICRONYCHIA

Nails Smaller Uni or Bilateral Identifies in Iso- Kikuchi

syndrome,Zimmerman-Laband syndrome,Turners syndrome

MACRONYCHIA

Naila are larger Uni Or Bilateral It is a/w Macrodactyly as in

Vonrecklinnghausens disease,Maffucci syndrome,Klippel-Trenaunay-Weber syndrome

POLYNYCHIA

Existence of two or more separate nails on one digit

Rare Congenital anomaly Lawrence-Moon-Biedl syndrome

POLYNYCHIA

RACKET NAILS AD Girls > Boys Thumbs >> Other fingers Epiphyses of terminal phalanx of

thumb closes prematurely by age of 7-10yrs,normally at 13-14 yrs

Distal phalanx of affected thumb is shorter & wider than normal

Affected nails are opaque,short with loss of normal curvature

Acquired: cong syphilis,acro osteolysis

RACKET NAILS

NAIL PATELLA SYNDROME

AD Nails partially or totally absent Linkage b/w locus controlling disorder &

ABO blood group LMX1B gene plays imp role,located on

long arm of ch 9 Tetrad constitutes Nail

dystrophy,Hypoplastic or absent patellae,Elbow dysplasia,Iliac horns

Thumb >> other finger Affected nails 1/3 or 1/2 of normal size

NAIL PATELLA SYNDROME

Lunula are triangular or V shaped Bilateral Post Iliac horns on x-ray

Pathognomonic Prenatal diagnosis by USG Possible Other features Lester iris,Open angle

glaucome,Palmoplantar hyperhidrosis, Scapular hypoplasia

NAIL PATELLA SYNDROME

Traingular Lunula

ISO KIKUCHI SYNDROME

Nails of index finger small or absent Unilateral or bilateral Miconychia is MC presentation Terminal bifurcation of distal phalanx is

characteristic feature

DOLICHONYCHIA

Nails appear narrow & long Normally ratio b/w length & breadth of

nail is 1 + 0.1 In these condition about 1.9 Identified in Ehlers danlos

syndrome,Marfans syndrome

CIRCUMFERENTIAL NAILS

Nails are Tubular Congenital seen in siblings Nails may cover all sides of one or

more fingers

CONGENITAL MALALIGNMENT OF BIGTOE

Lateral deviation of long axis of nail growth relative to distal phalanx one big toe or both

Medial deviation is rare Nails discoloured & thickened,often

traingular in shape MC identified in Monozygotic &

Dizygotic twins Nail grows temporarily fast than bone

of hallux,Realignment occurs when bone growth catches up with nail post natally

PERIODIC SHEDDING

Nails of great toe MC affected AD One or more nails shed repeatedly Regrowth of nail incomplete,defective Trauma from ill fitting shoes is MC

cause of repeated shedding of nails in sports persons

ALTERATIONS IN NAIL SHAPE

CLUBBING

Increased Transverse & Longitudinal nail curvature with hypertrophy of soft tissue components of digital pulp

Hyperplasia of fibrovascular tissue at base of nail gives Rocked nail appearance

Lovibonds angle, Curths angle, Schamroth’s window

Also K/A Hippocratic nails ,Watch glass nails

CLUBBING

Patient with cystic fibrosis

CLUBBING

Increased blood flow through vasodilated plexus of nail unit vasculature > Vessel hyperplasia

Altered Vagal tone Microvascular infarcts PDGF may responsible for vascular changes Painful clubbing indicative of periostitis

associated with HPOA,characteristic of thoracic malignancy

Pachydermoperiostosis : idiopathic,Puberty,a/w spade like thickening of foot & hands

CLUBBING

SHELL NAILS RACKET NAILS

Similar to clubbed nails Girls with bronchiectasis

around 5 yrs age Avulsion of nail plate

reveals atrophy of nail bed instead of hypertrophy noted in true clubbing

Broad & Shortened nails usually seen thumb & great toes

Similar to clubbed nails D/T stubby appearance

Arrest in distal phalangeal formation

CLUBBING

Lovibond angle : angle at junction of nail plate & proximal nail fold

Normally less than 160 degrees

Clubbing angle is more than 180 degrees

CLUBBING

Curth’s angle : Angle at Distal interphalangeal joint

Normally 180 degrees

Clubbing diminished less than 160 degrees

RACKET NAIL WITH CLUBBING RACKET NAILS

DISEASES OF NAIL BED

PSORIASIS

Multiple nail pits on dorsal nail plate

Oil staining of nail bed

Distal Onycholysis

PSORIASIS

Rough surface (Trachonychia )

Distal onycholysis Oil Staining

PSORIASIS

Punctate Leukonychia

Pathognomic Traumatic subungual

haemorrhage

PSORIASIS

Oil staining Longitudinal ridging Distal onycholysis Adherence of cuticle

to distal nail plate

PSORIASIS

Spongitic Pustule seen in Epidermis Absence of Granular layer,Acanthosis of Epidermis,Vascular Changes

LICHEN PLANUS

Nail involvement seen in 10 % of patients with LP

Nail thinning,ridging & fissuring Cicatricial out come ( Dorsal

Pterygium ) Yellowish discolouration Onycholysis

LICHEN PLANUS

Middle Finger : Proximal nail fold and matrix caused trachonychia,Longitudinal ridging,pterygium

Index Finger : Destruction of Nail Plate & Matrix with anonychia

LICHEN PLANUS

Involvement of nail matrix with pterygium

Scarring Pt had Hepatitis C

virus with erosive lichen planus

LICHEN PLANUS

Involvement of nail matrix

Thinning of thumbnail plates

LICHEN PLANUS :

Lichenoid infiltrate of nail bed and distal nail matrix * ,Nail plate

LICHEN PLANUS

HYPERKERATOSIS & SUPERFICIAL LYMPHOCYTIC INFILTRATE

BAND LIKE SUPERFICIAL LYMPHOCYTIC INFILTRATE ALONG WITH VACUOLAR DEGENRATION

DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS) Nail involvement in 96% cases Red or white longitudinal streaks ending in

a V shaped notch Streaks indicative of nail thinning Subungual hyper keratotic papules in

hyponychium Histologically similar to acantholysis of

skin in addition of multinucleated giant cells,epithelial hyperplasia seen

A case of SCC developing in chronic case of darier disease also noted

DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS)

Longitudunal streaks ( red & white )

Distal subungual hyperkeratotic papules

Wedge shaped fissuring of nail plate

DARIER-WHITE DISEASE (KERATOSIS FOLLICULARIS)

White and Red Longitudinal streaks

Distal notching

RED LUNULA Erythema of all or part of the lunula

may affect all digits, but most prominently the thumb

Dotted red lunulae have been reported in psoriasis and alopecia areata

red lunula seen in a single digit-Local disturbance of vascular flow- Benign tumour

Glomus tumour & Subungual myxoid cysts MC tumours.colour vary from blue & red

YELLOW NAIL SYNDROME The nails are yellow due to

thickening,rarely green tinge possibly due to secondary infection

There is increased transverse & longitudinal curvature,loss of cuticle & Lunula obscured

AD A/w lymphoedema at one or more

sites and respiratory or nasal sinus disease

YELLOW NAIL SYNDROME Histologically dense fibrous tissue

replacing Subungual stroma with numerous ectatic epithelium lined vessels,FB reaction may be seen

Obstruction of lymphatics by dense stroma leads to the abnormal lymphatic function found in the affected digits

Recurrent pleural effusions,Ch bronchitis, bronchiectasis,increased incidence of malignant neoplasms,nephrotic syndrome

YELLOW NAIL SYNDROME

Nails grow at slower rate 0.1-0.25 mm/week ( normal rate 0.5mm/week )

YELLOW NAIL SYNDROME

Diffuse Yellow to Green of nails

Nail thickening Excessive curvature

of from side to side

YELLOW NAIL SYNDROME

Treatment : Oral & Topical Vit E Oral & Topical Zn Pulse Itraconazole 400mg daily

/week/month Treatment of Chronic infection Complete reversion of nail changes

may occur spontaneously

HUTCHINSON’S SIGN

Brown black periungual pigmentation Possible sign of nail melanoma First described by

Hutchinson ,Pigmentation of proximal nail fold in a/w longitudinal melanonychia

Also identified in melanocytic naevi

HUTCHINSON’S SIGN

GREEN NAIL SYNDROME

Greenish black discolouration d/t Pyocyanin by P. aeruginosa

Exposure to water,detergents & soaps Barbers,Bakers & Dish washers DD: Melanoma,Aspergillus,Melanocytic

naevus Rx:Aminoglycosides,Acetic acid for 1 to

4 months

MEE'S LINES

Transverse white lines that run across the nail, following the shape of the nail moon

Uncommon after acute/severe illness, Arsenic

poisoning

MEE'S LINES

BROWN – GRAY NAILS

CYANOSIS

A bluish discoloration visible at the nail bases

patient with severe hypoxemia or hypoperfusion.

CYANOSIS

HALF-&-HALF NAILS

K/a Lindsay's nails Look for an arc of brownish

discoloration May occur in a small percentage of

people who have ch renal failure Other causes systemic diseases &

nutritional deficiencies

HALF-&-HALF NAILS

SPLINTER HAEMORRHAGES

Looks like a splinter underneath the nail

virtually 100% diagnostic of Sub-acute

Bacterial Endocarditis (SBE)

A bacterial infection affecting the

valves of the heart. Occasionally

caused by Trichinosis, a parasitic

infection caused by eating raw or

undercooked Pork.

SPLINTER HAEMORRHAGES

MELANONYCHIA

vertical pigmented bands or nail 'moles‘

a sudden change in the nail plate could indicate a malignant melanoma or lesion. 

Commonly occur in dark-skinned people, and are normal

Seek physicians care ,If you suddenly see this change in the nail plate.

MELANONYCHIA

LEUKONYCHIAWHITE DISCOLOURATION OF NAILS

True Leukonychia:Inherited disorder,all nail

affected,milky porcelian white nails

Subtotal Leukonychia :Proximal 2/3rd white rest pink

d/t delay in keratin maturation

Transverse Leukonychia: k/a Mees lines reflect

systemic disorder,chemotheraphy,poisining

Punctate Leukonychia:White spots of 1-3 mm

size,Manicure,alopecia areata

Apparent Leukonychia:Changes in nail bed

responsible for white appearance

Terry’s Nails: white proximally,normal distally,seen in old age,chronic renal failure,afterchemotheraphy,cirrhosis,cardiac failure,histology shows Inc vessel wall thickness & Melanin deposition

Muehrcke’s paired white bands : bands parallel to lunula in nail bed with pink in b/w white lines,seen in hypoalbuminaemia

LEUKONYCHIAWhite nails in distal free edges

TERRY'S NAILS

The nail looks opaque and white, but the nail tip has a dark pink to brown band.

May accompany cirrhosis, congestive heart failure, adult-onset diabetes, cancer or ageing.

ECZEMA OF THE NAIL

It affect the eponychium, nail plate and bed It causing pitting and onycholysis.

This is very rare

Eczema

HANG NAILS

Caused by minor injury or constant irritation through biting. The cuticle splits and appears as a small spike.

Hot oil manicures and regular use of a cuticle oil will help.

The spike can be clipped so it does not catch on things.

EGGSHELL NAIL

Nail plate is thin and abnormally flexible

chronic illness of systematic or nervous origin

It curves at the free edge and the nail plate can separate from the nail bed

ONYCHOLYSISDISTAL OR LATERAL SEPARATION OF NAIL FROM NAIL BED

Psoriatic onycholysis considered as a reference point for other forms

PO-typically distal,variable lateral involvement,area of separation appear white or yellow due to air beneath the nail,sequestered debris & glycoprotien exudate

Isolated islands of onycholysis present as Oil spots , salmon patches

ONYCHOLYSIS

Idiopathic-Painless separation of nail

from its bed-Overzealous manicure,wetting,cosmetic solvents-Condition starts at tip of

nail,spreads to distal one third of nail bed

-Colonization of candida albicans & pseudomonas pyocyanea

-Affected nails grow very quickly,more in women,

Secondary Psoriasis,trauma,funga

l infections,dermatitis,hypothyroidism,yellow nail syndrome,shell nail syndrome

- Photoonycholysis : treatment withpsoralens,doxycycline,demethylchlortetracycline,retinoids,anti cancer drugs

ONYCHOLYSIS

Distal onycholysis Loss of cuticle Psoriasis may be

cause

ONYCHOLYSIS

Most commonly associated with external trauma to the nail

Nail plate separates from the nail bed

ONYCHOLYSIS

The subungual space may be filled with hyperkeratotic debris

Distal nail bed separated from the nail plate in 2 nails.

ONYCHOLYSIS

Treatment : Patient advised cut away loosened nail &

apply local steroid with antibiotics ( prevent keratinisation of nail bed,that slows reattachment of nail)

Gentamicin eye drops for pseudomonas infection

2% thymol in chloroform for preventing infection

Milton regimen : soaking finger tips several nights week in venegar or sodium hypochlorite solution for 5 mins for prevention of recurrence

ONYCHOMYCOSIS A fungal or yeast infection which results in

Onychomycosis, can  invade through a tear in the proximal and lateral nail folds as well as the eponychium. 

This type of infection is characterized by onycholysis with evident debris under the nail plate.

It normally appears white or yellowish in color, and may also change the texture and shape of the nail.

The fungus digests the keratin protein of which the nail plate is comprised.  As the infection progresses, organic debris accumulates under the nail plate often discoloring it.If left untreated, the nail plate may separate from the nail bed and crumble off.

ONYCHOMYCOSIS(TINEA UNGUIUM)

White spots that can be scraped off the surface, or long yellowish streaks within the nail substance.

It attacks the free edge & moves towards the matrix

ONYCHOMYCOSIS

TINEA UNGUIUM – NAIL INFECTION

ONYCHOMYCOSIS

DSO

Distal subungual

hyperkeratosis and onycholysis involving most of the nail bed

of the great toenails; these

findings are usually

associated with tinea pedis.

Onychomycosis

ONYCHOMYCOSIS

NAIL CLIPPINGS SHOW SEPTATE HYPHAL ELEMENTS PROVEN TO BE TRICHOPHYTON SP WITH IN NAIL PLATE KERATIN

90 % Toe nail infections with Trichophyton,Microsporum,Epidermophyton sp

PAS staining most sensitive test

Stain reveals fungal organisms located in lower stratum corneum

Distal subungual Onychomycosis is MC form,caused by T.rubrum

It invades hyponychium & LNF finally yellow,onycholysis,sub ungual hyperkeratosis

T.mentagrophytes identified in superficial white OM,located in superficial nail plate

ONYCHOPHAGY

Bitten nails, often no free edge is visible

Nails look ragged and distorted

skin and nail bed can be exposed and raw

ONYCOPHOSIS

Refers to the growth of the horny epithelium in the nail bed

In other words a callus like growth on the nail plate

ONYCHOGRYPHOSIS

Elderly,Commonly toenails,usually Hallux

Favored by trauma Impairement of peripheral circulation

and innervation Nail acquires typical Ram’s Horn

shape d/t asymmetric growth Thick,hard,yellow brown nails

ONYCHOPTOSIS

Periodic shedding of one or more nails, either in whole or parts

This condition may follow certain diseases such as syphilis

PARONYCHIA

Paronychia is associated with separation of the seal between the proximal nail fold and the nail plate that provides entry for bacteria and leads to a localized infection of the paronychial tissues of the hands.

Symptoms may include inflammation, swelling & scaling

PARONYCHIA

An infectious and inflammatory condition of nail folds. Infection is bacterial

Ch paronychia may weaken defences and increase the risk of developing a fungal infection of the nail

PARONYCHIA

The nail fold is

erythematous, edematous,

with early abscess

formation, and is very

painful.

Paronychia

PTERYGIUM

Pterygium is the inward advance of skin over the nail plate,

Usually as a result of trauma to the matrix due to a surgical procedure or by a deep cut to the nail plate

Pterygium results in the loss of the nail plate due to the development of scar tissue 

Cortisone is used to prevent the advancement of scar tissue.  Never attempt to remove pterygium -instead, consult a physician for advice and treatment

NOTE: The 'true cuticle' is often referred to as Pterygium

PTERYGIUM Pterygium Inversum Unguis is an

acquired forward growth of the hyponychium characterized by live tissue firmly attached to the underside of the nail plate, which contains a blood supply and nerves. 

Possible causes are systemic,

hereditary, or from an allergic reaction to acrylics or solvents. 

Never use force to 'push back' the advancing hyponychium -- it is an extremely painful approach, and will result in a blood flow. 

PTERIGIUM

An abnormal winged like growth of skin (living tissue) on the nail plate

The skin is slowly stretched and dragged along the bed

caused by severe trauma such as warts, burns & blood circulation disorders.

PTERYGIUM

DORSAL PTERYGIUMVENTRAL PTERYGIUM

SCABIES OF NAIL

Commonly identified in crusted scabies Heaped up masses of keratin

accummulate underneath the nail Subungual material contains abundant

mites,source of infection Nails become dystrophic

SCABIES OF NAIL

SCABIES OF NAIL

Sarcoptes scabiei present in distal subungual hyperkeratotic debris found in hyponychium

Cause of persistent epidemics of scabies

Norwegian scabies severe involvement of nail folds

Scrapings of distal hyponychium- showing organism – Sarcoptes Scabiei

CANDIDA

Candida parapsilosis account for 20% infections

Candida common cause of Chronic paronychia,involve nail bed & nail plate in HIV

Candida albicans major cause of hypertropic nail bed infection in paediatric patients with HIV

CANDIDAL PARONYCHIA

MUCOCUTANEOUS CANDIDIASIS

CANDIDA

NAIL CLIPPINGS SHOW BUDDING YEASTS

PSEUDOMONAS

Pseudomonas bacterial infection can occur between the natural nail plate and the nail bed

Many people have been led to believe that the classic 'green' discoloration of this type of infection is some type of mold

In actuality, mold is not a human pathogen.  The discoloration is simply a by-product of the infection and is caused primarily by iron compounds

PSEUDOMONAS

Pseudomonas thrive in moist places; it feeds off the dead tissue and bacteria in the nail plate, while the moisture levels allow it to grow

The after effects of this infection will cause the nail plate to darken and soften underneath an artificial coating

PSEUDOMONAS

The darker the discoloration, the deeper into the nail plate layers the bacteria has traveled.  If the bacteria has entered between the nail plate and the nail bed, it will cause the same discolorations and may also cause the nail plate to lift from the nail bed.

PSEUDOMONAS

pseudomonas colonisation

ALOPECIA AREATA

First sign in 18% cases,More in children Pitting of nails,When pits uniformily

distributed on multiple nails,they often arranged in lines horizontially or vertically in a geometrical design k/a Glen-Plaid or Scotch-Plaid Pattern

ALOPECIA AREATA

SCOTCH-PLAID PATTERN

ASSESSING NAIL DISORDERS

Social History Footwear Medical History Physical exam Nail Assessment Special Investigations

SOCIAL HISTORY

Smoking Occupation Recreational Activities Places of residences (Qsld)

FOOTWEAR

Occupational Recreational Historical May need to inspect footwear

MEDICAL HISTORY

Need to conduct a review of systems (ROS) Dermatological Conditions important

eg psoriasis, atopy, Multi-System Disorders

eg RA, SLE, DE, CREST Cardiac/Pulmonary Problems Medications review Surgical Review Genetics review

PHYSICAL EXAMINATION

Vascular macro/micro circulation

Neurological Deficits?

Dermatological Below Knee

Gait Assessment

SUBJECTIVE NAIL ASSESSMENT

Events of Note How long has problem been present? Is it getting better or worse? Is it of concern to the client? Is pain present?

If so need to evaluate pain What previous treatments have been attempted?

Professional OTC Folk Need to follow up if any of these answers is positive

OBJECTIVE ASSESSMENT OF NAILS

Number of nails affected? Hands involved? Colour changes Extent of colour changes Extent of general changes Presence of toe deformity Presence of local exostosis May need to examine other areas

Scalp, elbows, knees

SPECIAL INVESTIGATIONS

Nail Specific Biopsy Microscopy (KOH test) Culture

X-Ray Blood Tests Further Vascular/Neurological Testing Cardiac Evaluation Genetic Testing

COMMON AETIOLOGIES

Trauma Infection

Fungal Bacterial

Systemic Disorders Direct Indirect

Neoplasms

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