Hitting the Nail On the Head

People often encounter changes in their nails. Some just ignore them while others find themselves not knowing what to do. Nail changes can be very important since it may be a sign of a major medical illness. It could also mean a very minor cosmetic problem causing major psychological trauma. Oftentimes, nail problems are misdiagnosed as fungal infection and treated as such.

Nail problems may manifest in a number of ways. A nail may show changes like thickening, thinning, abnormal curvature, discoloration, separation, of the nail plate from the nail bed, pitting, formation of grooves, dystrophy, and total destruction of the nail apparatus while the surrounding nail fold (the skin around a nail) may show inflammation. Some of these may be seen in several disorders while some specific conditions like onychomycosis may present two or three of these changes at the same time.

Thickening of the nail plate may be caused by repeated trauma, psoriasis and fungal infection while thinning of the nail plate may be caused by repeated immersion in water, impaired peripheral blood circulation, wearing of artificial fingernails, lichen planus and twenty nail dystrophy.

In very young children, it is common to have flattening of the nails. This condition may be hereditary or it may also be due to iron-deficiency anemia. Correction of the low iron levels will result to normalization of nail. For the fingernails, it usually takes six months for the nail to return to normal while for the toenails, it takes about one year. On the other hand, overcurvature of the nail is usually due to hereditary pincer nails.

Separation of the nail from the underlying nailbed is called onycholysis. It is usually caused by trauma, psoriasis, or fungal infection. It may also be a result of a photosensitivity reaction. Appropriate management for this condition is to cut the nails short, apply medical tape around the finger to cover the nail to prevent it from catching dirt and to avoid cleaning the underside of the nail with a pointed piece of stick or metal as this causes further trauma.

Clubbing of the nail is also considered an important nail change as this may signify chronic lung, liver or heart disease or may be hereditary. Pitting of the nails may be seen on the hand in cases of alopecia areata, psoriasis and eczema. These usually disappear in time once the dermatological problem has resolved, although some persist.

A myxoid cyst, glomus tumor or a growth under the nail may cause longitudinal grooves. Horizontal grooves on the other hand, may be due to an eczema around the nail, habitual ticking of the nail, a severe illness, malnutrition, or a severe form of stress.

Discoloration of the nail can vary from white, red, black, green, and blue to yellow. This may indicate a systemic disease affecting the liver or kidneys, skin cancer or melanoma, bacterial, or fungal infection, hematoma, racial pigmentation, side effect of intake of oral medications or it may mean nothing at all.

Ingrown toenails are common and often very painful. This condition can be due to several factors including hereditary overcurvature of the nail, convex cutting of the nail, wearing pointed toe and high-heeled shoes, fungal infection and occasionally, intake of oral retinoids.

A portion of the nail burrows under the skin surrounding the nail producing swelling, inflammation and pain. Treatment involves antiseptic soaks, topical or oral antibiotics if needed. Patients should be advised to cut the nails in a straight manner and not too short. For recalcitrant cases, simple nail removal can be done but has a 60-70 percent recurrence rate.

Melanoma usually presents initially with a longitudinal pigmented streak on the nail plate gradually involving the surrounding skin before destruction of the nail plate occurs. This rare condition is usually fatal and accounts for 1.5 to three percent of all melanomas. This occurs with equal incidence in blacks, Asians, and Caucasians.

Diagnosis if often made late and the mortality rate is more than 50 percent. Since there is lack of public awareness, mortality remains high. All cases suspected of being nail melanoma should be biopsied. If the streaks affect multiple nails, biopsy may not be performed as this may be due to racial pigmentation. If melanoma is confirmed on biopsy, standard treatment for early disease is digital amputation of the distal phalanx.

In summary, before starting treatment of any nail problem, an accurate diagnosis has to be made. It is important to identify trauma as the root of the problem or as a complicating factor. Protecting a damaged nail from further injury will help in the healing process.

It is important to do a biopsy on any suspicious-looking nail as this is the only tool that could lead to early detection of melanoma. Thus, with all these things in mind, it is important that one sees a dermatologist for any nail problem so that proper evaluation and management can be given.