Nail Disorders

Trachyonychia – 20 nail disease – Rough Nail

Trachyonychia or rough nails is a nail disorder that is commonly seen with lichen planus, psoriasis, and atopic dermatitis. It is commonly misdiagnosed as fungal nails but a biopsy will show that no fungal elements are present. Sometimes the nail can have multiple pathologies and therefore biopsy is crucial in the identification of the disease.

Subungual Hematoma – Blood Under Toenail

This disorder is a result of trauma to the nail. Blunt trauma, running, pedicure, or even tight shoes can cause blood to be trapped underneath the nail plate. The second toe, which is usually the longest, will develop a sublingual hematoma due to the chronic trauma it endures.

This condition is typically called joggers toe. If there is a lot of pain due to the trapped blood causing increased pressure under the nail then a podiatrist may drill into the nail plate or even take the nail off in order to relieve the pressure. The podiatrist will also check to make sure no openings in the skin are underneath the nail because the risk of bone and skin infection increases with the laceration.

Psoriatic Nail

Psoriasis can affect a variety of areas on the body. The skin, nails, and joints are the most common. Psoriatic nail disease presents with lifting of the nail off of the skin, oil spots, thickening, and pitting. Sometimes joint pain, Achille’s tendon pain, and swollen toes can be present with the nail symptoms. Psoriasis of the nails is very difficult to treat because it is so persistent. Treatment includes topical calcitriol, calcipotriente, corticosteroid injections into the nail matrix, topical potent steroids, and some systemic drugs which help to treat all of the above symptoms.

Paronychia – Infected Ingrown Toenail

A paronychia is caused by trauma, inflammation, infections, and ingrown toenails. The most common cause is the incurvated toenail. The skin surrounding the nail edge is traumatized with pressure and can lead to an opening in the skin. This opening is then subject to infection usually with a bacteria called Staph aureus. Commonly known as a Staph infection. A podiatrist will typically treat this condition with topical/oral antibiotics, removal of the offending nail border, and draining of the abscess if one is present. A chemical or physical matrixectomy may be performed if the paronychia reoccurs.

Onychomycosis – Nail fungus

Fungal nails is a very common disease state that typically occurs in diabetic and obese patients. The doctor may also diagnose Athlete’s foot infection with the nail fungus. A nail biopsy will be used to determine whether or not there is a fungal component to the diseased nail.

There are several types of onychomycosis:

Distal subungual onychomycosis is the most common type in adults and children. The nail plate is separated from the nail bed with discoloration, chalky debris below the nail, and callus around the skin. The doctor will also check for fungus in-between the toes so that spreading of the infection will not occur.

Proximal subungual onychomycosis is common in the immunocompromised patients. These are patients who have systemic diseases such as diabetes, HIV, organ transplants, or take medications that suppress the immune system. The discoloration of the nail plate occurs at the proximal nail fold and the tip of the nail is not affected. Superficial White Onychomycosis is when the nail displays a powdery material on the top of the nail. The podiatrist can scrape off this powder and send it to the pathologist as a biopsy. This type of nail problem occurs in tropical climates and is caused by Trichophyton mentagrphytes (molds).

Treatment for onychomycosis

Oral anti fungal such as terbinafine (Lamisil), itraconazole, fluconazole, griseofulvin, and topical ciclopirox topical can be used to treat the fungal nail. Urea nail gel can also be sued to soften and smooth the nail plate to achieve a better looking nail. A blood test is required before taking any oral medications in order to avoid adverse reactions.

Longitudinal Melanoychia – Striped Nail

A line of color on he nail may be caused by trauma, a benign lesion, certain metabolic disorders, and melanoma. African American’s show the greatest frequency of a striped nail. Biopsy is needed if clinical suspicion of melanoma occurs. If the lesion is not malignant then the nail will simply be monitored.

Lichen Planus of the Nail

This is a nail disorder that is a result of an inflammatory condition which can affect the skin, hair, nails, and mucous membranes. It can affect all ten toe nails and approximately ten percent of patients who have lichen planus have nails that are affected. The nails will have a rough look to them with longitudinal ridges. The ridges will have a dorsal wing formation at the proximal nail fold. The nail matrix has to be treated with steroid injections in order to prevent permanent nail damage. Urea gel can also help to smooth the nail out.

Myxoid Cyst

This is a skin cyst that occurs on the skin typically at the proximal nail fold. The cyst is usually round in shape and can be painful with pressure. The cyst can also cause the nail plate to become ridged due to its pressure onto the matrix of the nail. This cyst is treated by needling, steroid injections, and excision.

Onychogryphosis – Ram’s Horn Nail

This is a nail that is extremely long and curved like a claw. It is often referred to as a Ram’s horn nail. This condition usually occurs due to neglect of the nails. The condition can also be related to trauma to the nail in tight shoes or blunt trauma. Damage to the nail matrix on the sides of the nail can result in unequal growth of the individual sides of the nail.

Green Nail Syndrome

Green nails is usually caused by a bacteria called Pseudomonas. A moist environment will increase the likelihood of this condition since Pseudomonas is water loving. The reason the nail turns green is because the bacteria releases a pigment called pyocyanin. The bacteria does not infect the skin but does infect the underside of the nail plate. Podiatrists treat this condition by avoiding moisture and wetness to the nail and applying gentamicin topical solution to the nail.

Removal of the nail plate and subsequent treatment with the topical antibiotics can also prove beneficial.

Digital Fibroma

These are benign skin tumors usually found adjacent to the nail. When they get underneath the nail it can lift the nail up off the nail bed. They typically appear at puberty and may increase in number over time. If there are multiple fibromas around the nail this could be caused by tuberous sclerosis. This condition is called Koenen’s tumors and they can become elongated and pink. Excision of these lesions is the typical treatment.

Clubbing of Nails

The nail will present itself as bulbous, and rounded with an increase in soft tissue of the toe. Lung, thryoid, heart, and gastrointestinal disease can all cause this type of nail condition. Thirty percent of lung cancer patients display clubbing and an even higher percentage with Crohn’s disease. Vasodilation and increased blood flow could be a cause of this deformity. Treating the underlying condition is the best way to treat this condition.

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