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The Skin > Nail Disorders > Flashcards

Nail Disorders Flashcards

1
Q

Nail dystrophy

A

Abnormality of nail (not always fungal)

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2
Q

Onychonmycosis

A

Any fungal infection of the nail : Dermatophyte & non-Dermatophyte infection
Eg: Fusarium spp., Aspergillus spp., Candida spp.

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3
Q

Tinea unguium

A

Dermatophytic onychomycosis (Dermatophyte infection of the nails)
90% of onychomycosis
Eg: T. Rubrum, T. Interdigitale, T. Tonsurans, E. Floccosum

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4
Q

Local predisposing factors

A
  • nail not isolation
  • chronic tinea pedis (Dermatophyte in environment adjacent nail)
  • chronic paronychian (Candida spp) = support structures are inflamed, secondary infections
  • trauma/ other nail disorders
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5
Q

Host predisposing factors

A
  • poorly controlled DM
  • immunosuppression eg: HIV
  • peripheral vascular disease = impaired circulation to foot = slower growing thick nails = environment
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6
Q

Environment

A
  • occlusive footwear
  • sweating
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7
Q

How do fungi enter the nail?

A
  1. Distal/ lateral subungual
    — invasion via hyponychium
  2. Superficial white
    — direct penetration into dorsal surface of nail plate
  3. Proximal subungual (rare=cuticle protects)
    — invasion under proximal nail fold (immunocompromised hosts)
  4. Mixed pattern
    — >2 of above patterns in same nail
    (Lateral nail fold)
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8
Q

How do fungi affect nails?

A
  • subungual hyperkeratosis (keratin debris under nail plate)
  • crumbling
  • thickening
  • discoloration
  • nail plate destruction
    (All nail dystrophy)
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9
Q

Nail clippings & sub-ungual debris in lab

A
  • fungal microscopy & culture (/PCR available)
    — send nail clippings in saline
  • histology
    — fungal hyphae on formalin-fixed periodic acid schiff (PAS) stained nail clipping
    — send nail clippings in formalin
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10
Q

What is paronychia?

A
  • inflammation of nail fold (usually proximal)
  • can be divided into acute & chronic forms
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11
Q

Importance of cuticle

A
  • cuticle (eponychium) acts as seal to prevent irritants & pathogens entering beneath proximal nail fold
  • seal between proximal nail fold & nail plate
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12
Q

Acute paronychia: mechanism

A
  1. Nail biting/ sucking
    Manicures
    Ingrown toenails
    Medications eg: oral retinoids
  2. Minor trauma
  3. Port of entry for infections
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13
Q

Acute paronychia - pathogens?

A
  • bacterial infection
    = staph aureus/ strep pyogenes
    Recurrent acute (not always bacterial)
    = HSV (“hermetic whitlow”)
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14
Q

Chronic paronychia: mechanism

A
  1. Occupations that involve wet work, irritant contact dermatitis of hands
  2. Disruption of cuticle
  3. Irritant enter causing inflammation at proximal nailfild
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15
Q

Chronic paronychia- pathogens?

A
  • irritants & not primarily an infection
  • secondary infections do occur, Candida eg: candida albicans
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16
Q

Nail dystrophy causes

A
  • infections
  • benign/ malignant growths
  • cysts
  • systemic diseases
17
Q

Nail dystrophy: asymmetric involvement

A
  • external cause eg: Dermatophyte infection
  • if only one nail involved, local problem eg: cyst/ tumor
18
Q

Nail dystrophy: symmetric involvement

A

Internal cause eg: systemic diseases

19
Q

What is clubbing?

A
  • enlargement of soft tissue of digits
    — bulbous appearance
    — enlarged, curved nail plate
    — angle between proximal nail fold & nail plate widened to >180 degrees
20
Q

Congenital clubbing associated conditions

A
  • cystic fibrosis
  • congenital cyanotic heart disease
21
Q

Acquired clubbing associated conditions

A
  • bronchopulmonary disease
    — neoplasms (primary/ metastatic cancers, pleural tumors)
    — chronic infections (abscesses of lungs, TB)
    —bronchiectasis
    — pulmonary fibrosis
    — sarcoidosis
  • CVD eg: bacterial endocarditis
  • GITD eg: chronic active hepatitis, IBD
  • endocrine disease eg: hyperthyroidism/ Graves’ disease
  • other
22
Q

What is yellow nail syndrome?

A
  • slow nail growth
  • nails appear thickened
  • increased longitudinal curving
  • loss of cuticle
  • yellow color
23
Q

What causes yellow nail syndrome?

A

Pathophysiology not known
Associated conditions
- chronic lymphedema
- respiratory diseases
— chronic bronchitis
— bronchiectasis
— pleural effusions

24
Q

Apparement leukonychia

A

Leuko = white
Nychia = nails
Apparent
- nail plate in not truly white (nail plate is not the issue)
- problem is in the nail bed
- apply pressure to nail, white colour disappears
Eg: Muehrcke’s nails, half & half nails (Lindsay’s nails), terry’s nails

25
Q

Muehrcke’s nails

A
  • multiple transverse bands parallel to lunula
    Associations:
  • hypoalbuminaemia (nephrotic syndrome, malnutrition, liver disease) mechanism may be oedema of nailbed
  • chemotherapy, mechanisms?
26
Q

Half & half nails

A
  • apparent leukonychia of proximal half of nail
    Associations:
  • normal variant
  • chronic renal disease
    Mechanism:
  • uncertain
  • nail plate may be loosely attached to nailbed proximally
27
Q

Terry’s nails

A
  • whole nail white, approx. 2mm band at distal end
    Associations:
  • normal variant
  • liver cirrhosis (non-specific)
    Mechanism?
28
Q

Abnormal capillaries in proximal nail fold

A

Seen in autoimmune connective tissue diseases
- dermatomyositis & systemic sclerosis
- disease damage small capillaries of PNF
May only visible on capillaroscopy/ dermoscopy
Instead of regular capillary loops
- decreased capillary density (dropout, avascular areas)
- giant capillaries
- enlarged/ dilated capillary loops

29
Q

HIV & the nail

A

Fungal nail infections
- proximal subungual pattern
- Candida onychomycosis
Longitudinal melanonychia - bands of pigment on nail plate (other causes eg: familial, drug-induced, melanoma, other) not an NB sign of HIV
- HPV-induced SCC
- drug-induced (Zidovudine)

30
Q

Transverse depressions (Beau’s lines)

A
  • certain insults to nail matrix can cause a temporary arrest in growth of nail plate
    = transverse depressions in nail plate, grows out from matrix
    Eg of causes:
  • external trauma to nail matrix eg: manicures, nail biting
  • childbirth
  • systemic illness
  • chemotherapy
  • SJS
    Generally symmetrical in all nails
31
Q

Nail shedding (onychomadesis)

A
  • complete cessation of nail plate growth at nail matrix = shedding of nail plate
  • causes same as for transverse depressions (Beau’s lines)
  • after Cossack is A6 virus infection in children (hand, foot & mouth disease)
32
Q

Spoon shaped nails (Koilonychia)

A

Pathogenesis poorly understood
Potential causes eg:
- severe iron deficiency
- amyloidosis
- trauma
- idiopathic
- physiological in 2nd-4th toes of young children (under 5 years old)

33
Q

Psoriasis & the nail

A
  • clinical presentation depends on what part of the nail is affected by psoriatic inflammation
  • matrix(distal & proximal) = pitting
  • nail bed = subungual hyperkeratosis
  • onycholysis (nail plate separates from nail bed)
  • “oil drop” sign (yellow/orange discoloration visible through nail plate

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