Nail changes in dermatological diseases: A cross-sectional study at a tertiary care hospital

Infective diseases

Onychomycosis was the most common infective as well as commonest nail disease overall (67% of cases). The nail changes seen were chromonychia in 24 (44%) patients seen as brown to black colour, and leukonychia in 3 (6%) patients have [Figure 1a]. Acute Paronychia was commonly seen in females, and the right hand was the most commonly affected. Periungual warts were seen in five patients. Onycholysis was seen in one case due to a wart in the nail bed region [Figure 1b]. Nail changes with hand-foot-mouth disease were seen in two patients, both presenting with onychomadesis. Onychoscopy of onychomycosis showed longitudinal spike pattern, aurora borealis pattern and ruin pattern [Figure 2].

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Figure 1:

(a) White superficial onychomycosis of toenails and (b) periungual wart on nail bed on finger nail showing onycholysis.

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Figure 2:

(a) Onychoscopic image of onychomycosis showing chromonychia and longitudinal spike pattern (Illucco IDS 1100, × 10, polarised). (b) Onychoscopic image showing friable subungual hyperkeratosis or ruin pattern in onychomycosis (Illucco IDS 1100, ×10, polarised).

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Inflammatory/Autoimmune diseases

Out of 20 patients with psoriasis, affecting the nail matrix, pitting was the most frequent change seen [Figures 3 and 4]. Nail changes in alopecia areata were seen in two patients in the form of regular pitting [Figure 5a]. Out of four patients with lichen planus, nail changes such as thinning, ridging, v-shaped nicking, pterygium, and onychomadesis were seen [Figure 5b]. Nine patients with autoimmune connective tissue diseases were included [Figures 6-8]. In two patients with pemphigus vulgaris, the nail changes observed were thickening, yellowish discoloration, nail dystrophy, onychomadesis, and Beau’s lines. Two patients of erythroderma were included in our study. One was secondary to photodermatitis (eczematous dermatitis), and one was secondary to psoriasis. In patients with eczema, the most common nail change seen was eczema of the nail fold.

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Figure 3:

(a) Coarse pits, onycholysis of nail plate and erythematous plaques with scaling of nail folds. (b) Trachyonychia of nail (rough type) in psoriasis.

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Figure 4:

(a) Onychoscopic image showing coarse irregular pitting and onycholysis in psoriasis. (Illucco IDS 1100, ×10, polarised) (b) Onychoscopic image of subungual compact hyperkeratosis in psoriasis (Illucco IDS 1100, ×10, polarised).

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Figure 5:

(a) Fine, regular pitting in alopecia areata. (b) Pterygium secondary to lichen planus.

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Figure 6:

(a) Pitted scars on finger pad (Early stage of scleroderma). (b) Resorption of tuft of fingers (late stage of scleroderma).

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Figure 7:

(a) Onychoscopic image of microhaemorrhages (black circle) on proximal nail fold capillaroscopy in active stage of scleroderma (Dino-Lite AM3111, polarised, ×2060) and (b) onychoscopic image of avascular areas (black arrow) in proximal nail fold in late stage of scleroderma (Dino-Lite AM3111, polarised, ×200).

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Figure 8:

(a) Onychoscopic image of systemic lupus erythematosus showing meandering capillaries (white circle) (Dino- Lite AM3111, polarised, × 200) and (b) Onychoscopic image showing bushy capillaries in dermatomyositis (black circle) (Dino-Lite AM3111, polarised, × 200).

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Genodermatoses

Patients with genodermatoses included in our study were Darier’s disease, Apert syndrome [Figure 9a], palmoplantar keratoderma (PPK), tuberous sclerosis [Figure 9b] and epidermolysis bullosa (EB). Apert syndrome is a rare genodermatosis with dysmorphic facies, syndactyly of fingers and toes.

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Figure 9:

(a) Syndactyly in Apert syndrome and (b) fibrokeratoma on finger nail in a patient having angiofibromas on face (case of tuberous sclerosis).

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Figure 10:

(a) Subungual fibrokeratoma on finger nail and (b) cryptonychia of toe nail.

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Miscellaneous disorders

Among nail dyschromias, melanonychia was the most frequently observed change. Other types of chromonychia noted included both brown endogenous and exogenous chromonychia, as well as blue lunulae.

Out of four patients having nail changes secondary to trauma, two patients had a subungual hematoma, one had traumatic onycholysis, and one had traumatic pterygium. Two patients of fibrokeratoma (nail bed and proximal nail fold) were included in our study [Figure 10a]. Out of three patients with onychocryptosis, two patients had granulation tissue at the nail fold and incurving of the nail plate [Figure 10b]. Among patients presenting with nutritional deficiency related dermatoses, nail plate changes seen were ridging, koilonychia, thinning of the nail plate, and whitening and hardening of all the nails. Nail matrix changes included dystrophy and onychomadesis.

Infective diseases

Among the cases of onychomycosis, distal lateral subungual onychomycosis was the most common type, which is in concordance with other studies.^[4-7] Pitting was seen in one patient with onychomycosis, which was not found in the above quoted studies. Pitting is reported to be a rare finding in onychomycosis.^[8] Other features we saw, were in concurrence with the study by David et al.^[4]; however, additional findings which they reported included Beau’s lines and greenish discolouration.^[4] Onychoscopic changes suggestive of onychomycosis in the form of spiked and jagged edges, ‘Aurora borealis’ pattern, and subungual ‘ruins’ pattern (65%) were seen in 18 (90%), 17 (85%) and 13 (65%) patients, respectively, by Ankad et al.^[9] Other findings including lamellar microsplitting and defined patterns of leukonychia, reported in some studies^[10,11], were not visualised in our cases. Regarding acute paronychia, our study had a male-to-female ratio of 1:5, similar to the report by Rani et al.^[6] The right hand was found to be affected more often, similar to other studies.^[6,7] This could be because of the longer duration of contact with water.

Patients with hand-foot-mouth disease have been reported to develop nail findings in the form of Beau’s lines, onychomadesis, yellowish discolouration of nail plate, and leukonychia.^[12] These changes resolve spontaneously after 8 weeks.^[13] Five patients with periungual warts in our study was a higher proportion as compared to previous study by David et al.^[4], who reported warts in one patient out of 550 patients; or Rathi et al.^[7] who reported nine patients among 225 patients. This difference is probably due to the varying prevalence of this infectious condition.

Inflammatory/autoimmune conditions

Table 3 compares the findings in our study with other studies of nail changes in psoriasis. Onychoscopic findings of pitting, onycholysis, and subungual hyperkeratosis were seen in 90%, 75% and 20% cases, respectively. Similar results were reported in previous studies.^[14,15] Onycholysis may occur due to multiple reasons. Most common causes of onycholysis include nail psoriasis and onychomycosis, followed by less common causes including trauma and warts. In psoriasis, the onycholysis frequently has an erythematous border at its proximal edge. In onychomycosis, the onycholysis has a jagged proximal edge.^[9] Differentiating between nail psoriasis and onychomycosis may be clinically tricky at times. Onychoscopy may come in handy at such times. The prevalence of onychomycosis is higher in patients with psoriasis than in the general population. Furthermore, both conditions may coexist. Thus, clinically, psoriasis patients whose nails appear resistant to treatment should be evaluated for onychomycosis by relevant investigations.^[16].

Rathi et al., had reported one patient with alopecia areata in their series, presenting with nail pitting.^[7] In the study by Rani et al., pitting was seen in 64% of patients.^[6] In the study conducted by David et al., superficial pits in a scotch plaid pattern were seen in all patients with alopecia areata.^[4] Nail involvement in alopecia areata is commonly seen in children or in those with severe forms of alopecia. Pitting is a common feature, presenting as a fine and geometric pattern in alopecia areata, in contrast to the coarse pits seen in psoriasis. Nail involvement is considered a poor prognostic marker in alopecia areata. Thus, their presence and assessment of severity may guide management decisions. Nail changes often occur simultaneously with hair loss but may precede or follow hair changes.^[17]

Table 4 compares the findings in nail lichen planus in our study with other similar studies. Longitudinal ridging, fissuring, nail plate thinning, and trachyonychia were common findings in nail lichen planus. Melanonychia is the most common finding in some studies which was not observed in our study.^[18]

Trachyonychia is a disorder of the nail unit that most commonly presents with rough, longitudinally ridged nails (opaque trachyonychia) or, less frequently, with uniform, opalescent nails with pits (shiny trachyonychia). The rough type is considered to be the more severe type. Dermatologic conditions commonly associated with trachyonychia include alopecia areata/alopecia universalis, lichen planus, and psoriasis.^[19]

There are both clinical as well as dermoscopic changes in autoimmune connective tissue disorders. Scleroderma presents as a shortening of fingers, fingertip scars, digital necrosis, pseudo-clubbing, and ragged cuticles as prominent clinical changes.^[7,20] Nail fold capillaroscopic changes are primarily divided into three patterns signifying early, active, and late disease, as described by Grover et al.^[21] Clinical nail changes in lupus erythematosus include onycholysis, discolouration, longitudinal ridging, nail fold erythema, etc.^[20] Nail-fold capillaroscopy anomalies are detected less frequently and less consistently in systemic lupus erythematosus. Extremely lengthy capillary loops (>750 m), meandering capillaries, and a large subpapillary venous plexus are the most commonly reported anomalies.^[21] Clinical nail changes seen in dermatomyositis include ragged cuticles and erythema of the nail fold. Apart from systemic sclerosis, dermatomyositis has the most consistent nail-fold capillaroscopy abnormalities.^[22] Increased micro haemorrhages and elongated capillaries are well correlated with myalgia and arthralgia, respectively. Avascular areas and budding or bushy capillaries, which suggest ischemia and revascularisation, respectively, are observed most frequently in dermatomyositis.^[22]

In pemphigus vulgaris, nail manifestations include paronychia, Beau’s lines, onycholysis, subungual haemorrhages and onychomadesis. The type and onset of nail changes may reflect varying severity of the disease. Nail involvement frequently occurs before or with a flare of disease and is rarely a part of the initial presentation.^[23] Thus, nail involvement in pemphigus warrants attention as it may serve as a harbinger of the flare-up of disease or severe disease, thus warranting aggressive systemic treatment. The resolution of nail diseases takes longer than resolution of skin manifestations.^[24]

In erythroderma, nail changes commonly observed are shiny nails, subungual hyperkeratosis, longitudinal ridging, onycholysis, nail dystrophy, Beau’s lines, and onychomadesis.^[6,7] Nail changes are most commonly seen in psoriatic erythroderma, as per the study by Mathew and Sreedevan.^[25] Nail changes can act as a pointer to the causative disease like psoriasis.^[6]

Nail changes seen in eczema in various studies include onycholysis, ridging, subungual hyperkeratosis, and pitting.^[4-7] Nail changes in eczema are more frequent in patients who have lesions on the hand and foot; this indicates that the involvement of the nail bed or matrix in continuity with the skin on hands and feet may result in nail changes.

Genodermatoses

Darier’s disease frequently presents as longitudinal red and white bands, V-shaped nicking of fingernails, nail dystrophy, etc.^[4-7] These features are not exclusive to Darier’s disease, but can provide valuable clues for diagnosis.

Apert syndrome is a rare entity. With only a few cases reported in the literature, our case would be instrumental in adding to the existing pool of data.

In tuberous sclerosis, fibromas or Koenen’s tumours appear during puberty and are present in 50% of cases.^[26] In a study by Liebman et al., 61 patients had ungual fibromas. About half of the patients with ungual fibromas had both periungual and subungual lesions, with periungual fibromas predominating overall. Periungual fibromas were seen as pink papules originating from under the proximal or lateral nail fold. The underlying nail plate had a longitudinal groove.^[27]

Nail involvement is one of the earliest symptoms of EB and can occur even before skin blistering. In EB simplex, onychomadesis and onycholysis can occur in severe subtypes, whereas in junctional and dystrophic forms, nail changes are closely associated with the severity of the disease. In these subtypes, nail involvement is in the form of loss of nails in severe forms and onycholysis and dystrophy in milder forms.^[28] Rathi et al. also found two patients with EB where the nails were dystrophic in both patients and onycholysis was seen in one patient. Both patients had finger nail involvement. None of these had any history of skin or systemic disease.^[7] It is in contrast to our cases where one patient had haemorrhagic blisters on the skin.

PPKs are sometimes present with nail abnormalities. Pachyonychia congenita typically presents with toenail dystrophy, focal keratoderma and plantar pain. David et al. had also reported one patient of PPK with nail changes.^[4] In study by Rani et al., three cases were PPK, with thickening, discoloration, and Beau’s lines involving nails were reported.^[6] The findings seen in our patients were ridging, and dystrophy.

Miscellaneous

Nail dyschromias are often a cause of concern to patients. It represents a colour difference in the material or the surface of the nail plate or subungual tissue. The most prevalent type of nail dyschromia is leukonychia, which is an opaque white staining of the nail. There are three forms of leukonychia: true leukonychia, apparent leukonychia and pseudoleukonychia. Melanonychia is a black-brown darkening of the nail caused by melanin deposition. There are three types of melanonychia: longitudinal, diffuse and transverse. Blue chromonychia is most commonly attributable to drug use (including antimalarials, chemotherapeutic agents and azidothymidine). Additional causes include exposure to silver salts, Wilson’s disease, glomus tumour of the nail and digital malformations. Other types of chromonychia are also seen (yellow, red or green types).^[29,7]

In our study, melanonychia was found as an isolated finding in six patients, and in conjunction with other findings (such as Darier’s disease and onychomycosis) in a number of patients. Nail dyschromia occurs due to many causes and we found five patients with isolated nail chromonychia, namely, three dark brown, one blue discolouration of lunulae, and one punctate leukonychia.

Another aspect of chromonychia is that they may be due to endogenous or exogenous causes. The exogenous chromonychia has a proximal margin parallel to the margin of the proximal nail fold, whereas the endogenous chromonychia is parallel to the convex margin of the lunula.^[4,7,30]

The nail changes may be associated with occupation. A patient with traumatic pterygium who was a farmer by occupation, and another with onycholysis who was a carpenter, were noted. We found two cases of subungual hematoma of the nail bed secondary to trauma. While it is a benign and self-resolving condition, it may sometimes be confused with more sinister diagnoses like subungual melanoma.

Onychocryptosis was seen in three cases in our study. In the study by Rathi et al., it was found in one patient (0.4%),^[7] whereas in the study by David et al., it was found in 11 (2%) patients.^[4] In a study by Rani et al., six patients were found to have ingrown toenails (3.77%).^[6]

A study by Palaniappan et al. that described the demographic and clinical characteristics of fibrokeratoma found that most lesions occur on the fingers with the dorsal involvement being more common.^[31] In our study, we found a subungual fibrokeratoma, which is a rare finding and a dorsal finger fibrokeratoma, which is common.^[32]

In our study, koilonychia was seen in two patients similar to other studies.^[4,6,7] Dystrophy was seen in two patients and onychomadesis was seen in one patient. Onychoschizia, ridging, thinning and hardening of nail plate were the other changes seen. Nutritional changes in nails provide clues to underlying deficiencies when other signs may not be evident. Due to their relatively slower rate of regeneration as compared to the skin, nails provide evidence of any disease that may have occurred in the recent past when the skin manifestations have disappeared.