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Nail changes may be primary where the disease is affecting the nail or secondary to a systemic disease.

Infections :either bacterial , fungal or in the course of different systemic infections. These were discussed in the previous chapters.

Nail hypertrophy

Hypertrophy of the nails may be due to :

Congenital such as in Mal de Meleda .

Acquired - The nail becomes deformed with claw like appearance .

Fig. 433. Hypertrophic Nails (Congenital)


Nail hypertrophy may be due to different factors mainly :

Failure to cut nails regularly and repeatedly .


Fig. 434. Mal de Meleda (Nail Hypertrophy)


Peripheral vascular disorders.

Nail atrophy

The nail becomes thin ,rudimentary and smaller size .Nail atrophy may be congenital or acquired :


Diseases which can cause nail atrophy are the following:

  • Lichen planus

  • Epidermolysis bullosa

  • Darrier‘s disease

  • Vascular disturbances.

  • Infections such as leprosy.

Nail shedding

Fig. 435. Nail Dystrophy (Lichen planus)


  • Penicillin allergy

  • Keratosis punctata

  • Skin diseases

  • Paronychia: paronychia may be bacterial or fungal.

  • Psoriasis of nails

Fig. 436. Onychomycosis

Fig. 437. Nail Dystrophy (Fungal infections)

Nail changes in psoriasis :

Furrows and nail pitting .

Transverse depression of the nail .

Splinter hemorrhage.

Subungual debris and keratoses .


Lichen planus : Nail changes may be associated with skin and mucous membrane manifestations of lichen planus or the disease is localized to the nails only.

                                                                            Fig. 438. Nail Shedding (Psoriasis)



Nail changes in lichen planus are :

Longitudinal grooving of the nail.

Bulging at the proximal nail folds.


Nail atrophy

Permanent loss of nails.

Hippocratic fingers

Clubbing of fingers is a manifestation of a large number of systemic diseases.

Nail changes and that of the terminal phalanges give the “drum stick“ appearance of nails.

Clinical Feature

Nail bulging

Convex curved nail in both longitudinal and transverse directions.

Thickened eponychium.

Diseases associated with clubbing:

Respiratory diseases : bronchiectesis, chronic bronchitis, bronchogenic carcinoma, emphysema, tuberculosis.

Liver diseases : biliary cirrhosis

Congenital heart diseases.

Nails in the course of chronic eczema: deformities, nail brittling,atrophic and hypertrophic changes may occure.


                                           Fig. 439b. Nail dystrophy with Alopecia 




                                                                                                                               Fig. 439a. Nail changes and chronic eczema


SPOON NAILS (koilonychia)

The nail is thin and concave from side to side with everted edges.


                                                                                                                       Fig 439b. Spoon nails


  • Iron deficiency anaemia

  • Polycythema

  • Coronary disease

  • Syphilis

  • Acanthosis nigricans

  • Plummer-Vinson‘s syndrome.

  • Strong alkalis as soaps

  • Petroleum products .

Beau‘s Lines

Transverse lines and furrows at the nail lanula .



Systemic infections such as measles.

Drug reaction.

Brittled nails


Strong soaps

Nail polish

Vitamin deficiency: Vitamin A and B.

Pitted nails



Lichen planus

Nail biting (Onychophagia)

This is a common habit in children, biting and clipping of the tip of the nails by teeth. All fingernails are often bitten, but occasionally, one or more are spared. The nail is often bitten right back to the point of separation from the nail.                 

                                                     Fig.439c. Nail biting

The cuticles and lateral nail walls are often bitten and so become irregular and broken. Peri ungual warts are more common in nail biters.

Ingrowing nail 


                                                                                                                                                                       Fig.439d. Pyogenic paronychia &Ingrowing nail

This is due to different factors mainly : repeated trauma to nail, tight shoes, bony malformation of the big toe and others.


This is essentially similar to the habit tic but is more closely allied to parasitophobia as the patient picks off pieces of nail fold and may claim that they contain parasites. A rough and irregular nail and nail fold results.

The nail and cosmetics

Different nail preparations or paints of nails may have local reaction affecting the nail and the adjacent tissues. These products may affect babies and children indirectly from their mothers due to contact of their skin with these applied cosmetics on the mothers‘ nails. Nail cosmetics include the nail polish and the nail removal, which is composed of various solvents such as acetone.

Clinical Manifestations:

Contact dermatitis to the adjacent tissue .

Dryness of the nails .

Brittled and fractured nails .




                  White nails (congenital                                                                                                                                                                                             


Punctate type: occurs as a result of:


Systemic diseases as typhoid fever , nephritis .

Fungal infections .

Black nails


Adisson‘s disease

Cushing‘s disease

Pigmented nevus


Fig. 440. Nail Hyperpigmentation 
(Cushing's Disease)

Deep X-ray therapy

Infections especially due to pseudomonas .

Longitudinal black bands



Junction nevus

Green nails

These types of color changes of the nails occur with pseudomonas aeruginosa infections.

Yellow nails


Drugs and chemicals : such as chrysarobin , Resorcin , anthralines .

Infections : syphilis

Blue nails


Drugs : Mepacrine


Melanotic whitlow

Fig. 441. Blue Nail

Brown nails


Potassium permanganate soaks

Mercury compounds

Drug reaction: Anti-malarial drugs, Phenolphthalein.

Post inflammatory

Fig. 442. Azure Nails

Azure nails

Blue discoloration of the lanula occurs in chronic liver diseases such as hepatolenticular degeneration .

Fig. 443. Yellow Nails



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  2. Barth JH, Dawber RPR. Diseases of the nails in children. Paed Dermatol 1987; 12: 275-90.

  3. Barlow AJE, Chattaway FW, Holgate ML et al. Chronic paronychia. Br J Dermatol 1970; 82: 448-53.

  4. Baran R, Dawber RPR, eds. Diseases of the Nail and their Management. Oxford: Blackwell Scientific Publications, 1984; chapter 4, 105-20.

  5. Baran R, Barth J, Dawber RPR, eds. Nail Disorders. London: Dunitz Ltd, 1991: 78-101.

  6. Colomb D. Antimalarial nails pigmentation. Bull Soc Fr Dermatol Syphiligr 1975; 82: 319-22.

  7. Daniel CR, ed. Paronychia. In: Dermatologic Clinics 1988; 3(3) 461-4.

  8. Daniel CR. Pigmentation abnormalities. In: Scher RK, Daniel CR, eds. Nails: Therapy, Diagnosis, Surgery. Philadelphia: WB Saunders Co, 1990: 153-66.

  9. Eastwood JB, Curtin JR, Smith EKM et al. Shedding of the nails apparently induced by large amounts of cephoridine and cloxacillin in 2 anephric patients. Br J Dermatol 1969; 81: 750-2.

  10. Franks SB, Coton HJ, Mirkin W. Photo-onycholysis due to tetracycline. Arch Dermatol 1971; 103: 520.

  11. Ganor S. Chronic paronychia and psoriasis. Br J Dermatol 1975; 92: 685-8.

  12. Runne U, Orfanos CE. The human nail. Curr Probl Dermatol 1981; 9: 102-49.

  13. Samman PD. The Nails in Disease 3rd edn. London: Heinemann, 1978: 14.

  14. Turano AF. Beau‘s lines in infancy. Pediatrics 1968; 41: 996-4.


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