Nail Pathology


The visual appearance of the fingernails and toenails may suggest an underlying systemic disease. Clubbing of the nails often suggests pulmonary disease or inflammatory bowel disease. Koilonychia, or “spoon-shaped” nails, may stimulate a work-up for hemochromatosis or anemia. In the absence of trauma or psoriasis, onycholysis should prompt a search for symptoms of hyperthyroidism. The finding of Beau’s lines may indicate previous severe illness, trauma, or exposure to cold temperatures in patients with Raynaud’s disease. In patients with Muehrcke’s lines, albumin levels should be checked, and a work-up done if the level is low. Splinter hemorrhage in patients with heart murmur and unexplained fever can herald endocarditis. Patients with telangiectasia, koilonychia, or pitting of the nails may have connective tissue disorders.

Careful examination of the fingernails and toenails can provide clues to underlying systemic diseases (Table 1). Clubbing, which is one example of a nail manifestation of systemic disease, was first described by Hippocrates in the fifth century B.C.1 Since that time, many more nail abnormalities have been found to be clues to underlying systemic disorders.

  • Clubbing
    Inflammatory bowel disease, pulmonary malignancy, asbestosis, chronic bronchitis, COPD, cirrhosis, congenital heart disease, endocarditis, atrioventricular malformations, fistulas
  • Koilonychia
    Iron deficiency anemia, hemochromatosis, Raynaud’s disease, SLE, trauma, nail-patella syndrome
  • Onycholysis
    Psoriasis, infection, hyperthyroidism, sarcoidosis, trauma, amyloidosis, connective tissue disorders
  • Pitting
    Psoriasis, Reiter’s syndrome, incontinentia pigmenti, alopecia areata
  • Beau’s lines
    Any severe systemic illness that disrupts nail growth, Raynaud’s disease, pemphigus, trauma
  • Yellow nail
    Lymphedema, pleural effusion, immunodeficiency, bronchiectasis, sinusitis, rheumatoid arthritis, nephrotic syndrome, thyroiditis, tuberculosis, Raynaud’s disease
  • Color change
  • Terry’s (white) nails
    Hepatic failure, cirrhosis, diabetes mellitus, CHF, hyperthyroidism, malnutrition
  • Azure lunula
    Hepatolenticular degeneration (Wilson’s disease), silver poisoning, quinacrine therapy
  • Half-and-half nails
    Specific for renal failure
  • Muehrcke’s lines
    Specific for hypoalbuminemia
  • Mees’ lines
    Arsenic poisoning, Hodgkin’s disease, CHF, leprosy, malaria, chemotherapy, carbon monoxide poisoning, other systemic insults
  • Dark longitudinal streaks
    Melanoma, benign nevus, chemical staining, normal variant in darkly pigmented people
  • Longitudinal striations
    Alopecia areata, vitiligo, atopic dermatitis, psoriasis
  • Splinter hemorrhage
    Subacute bacterial endocarditis, SLE, rheumatoid arthritis, antiphospholipid syndrome, peptic ulcer disease, malignancies, oral contraceptive use, pregnancy, psoriasis, trauma
  • Telangiectasia – Rheumatoid arthritis, SLE, dermatomyositis, scleroderma

Source: American Family Physician


Charles White, DPM
Foot & Ankle Surgery / Podiatry

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