Nail Abnormality and Associated systemic disease

Nail Abnormality and Associated systemic disease:

Let’s study them all in one post!!

Definition: Clubbing (also called Hippocratic fingers) is defined as a selective bulbous enlargement of the distal segment of a digit (fingers and toes) due to an increase in connective tissue especially on the dorsal aspect resulting in loss of the onychonychia angle.

Causes of clubbing:

A) Respiratory:

  1. Neoplasms: Bronchogenic carcinoma (especially squamous cell carcinoma), metastasis to lung, mesothelioma.
  2. Suppurative lung disease: Bronchiectasis, lung abscess, cystic fibrosis, empyema.
  3. Asbestosis (with mesothelioma).
  4. Sarcoidosis.
  5. Cystic fibrosis.
  6. Pulmonary arteriovenous fistula.
  7. Interstitial lung diseases.

B) Cardiovascular:

  1. Infective endocarditis.
  2. Cyanotic congenital heart diseases.
  3. Atrial myxoma.
  4. Eisenmenger’s syndrome.

C) Gastrointestinal:

  1. Inflammatory bowel disease (Ulcerative colitis and Crohn’s disease).
  2. Primary biliary cirrhosis.
  3. Hepatoma.

D) Miscellaneous:

  1. Hereditary, idiopathic: (Pachydermoperiostosis or Touraine-Solente-Gole syndrome).
  2. Unidigital clubbing occurs in repeated trauma.
  3. Unilateral Clubbing occurs in Hemiplegia (long standing).
  4. Vascular disease:
    – Aneurysm: Subclavian artery, brachiocephalic trunk.
    – Pre-subclavian coarctation of aorta (left-sided clubbing).
    – Pancoast tumor.
    – Unilateral erythromelalgia.
    – Arteriovenous fistula used for hemodialysis.
    – Infected arterial graft.

Spoon-shaped nails (transverse and longitudinal concavity)

Found in:
a. Iron deficiency anemia,
b. Rarely in hemochromatosis,
c. Raynaud’s disease,
d. Systemic lupus erythematosus,
e. Hypothyroidism or hyperthyroidism.

Punctate depressions in nails.

Found in:
a. Psoriasis,
b. Reiter’s syndrome,
c. Pemphigus,
d. Lichen planus,
e. Alopecia areata,
f. Rheumatoid arthritis.

Distal nail plate separated from nail bed, white discoloration of the affected part of the nail.

Found in:
a. Psoriasis,
b. Local infection,
c. Hyperthyroidism,
d. Sarcoidosis,
e. Trauma,
f. Amyloidosis,
g. Connective tissue disorders,
h. Pellagra.

Beau’s lines:
Transverse linear depressions over nails, move distally with the growth of nail.

Found in:
a. Any severe systemic illness that disrupts nail growth,
b. Raynaud’s disease,
c. Pemphigus,
d. Trauma.

Proximal separation of nail plate from nail bed.

Found in:
a. Trauma,
b. Drug sensitivity,
c. Poor nutrition,
d. Pemphigus vulgaris,
e. Kawasaki disease.

Yellow nails:
Nail has a ‘heaped-up’ or thickened appearance, yellow in color, with obliteration of lunula.

Found in:
a. Lymphedema,
b. Pleural effusion,
c. Immunodeficiency,
d. Bronchiectasis,
e. Sinusitis,
f. Rheumatoid arthritis,
g. Nephrotic syndrome,
h. Thyroiditis,
i. Tuberculosis,
j. Raynaud’s disease.


Terry’s (white) nails:
Most of the nail plate turns white with obliteration of lunula, uniformly affects all nails.

Found in:
a. Liver failure,
b. Cirrhosis,
c. Diabetes mellitus,
d. Congestive heart failure,
e. Hyperthyroidism,
f. Malnutrition.

Half and half nails (Lindsay’s nails):
Proximal portion of nail bed is white because of nail bed edema (half brown, half white appearance).

Found in:
a. Renal failure,
b. HIV infection,
c. Crohn’s disease.

Azure lunula (blue nails):
Found in:
a. Hepatolenticular degeneration (Wilson’s disease),
b. Silver poisoning,
c. Quinacrine therapy.

Mees’ lines:
Transverse white bands affecting multiple nails, move distally with nail growth.

Found in:
a. Arsenic poisoning,
b. Hodgkin’s lymphoma,
c. Congestive heart failure,
d. Leprosy,
e. Malaria,
f. Chemotherapy.

Muehrcke’s lines:
Pairs of transverse white lines that disappear on applying pressure, do not move with growth of nail.

Found in:
a. Specific for hypoalbuminemia of any cause.

Dark longitudinal streaks:
Found in:

a. Melanoma,
b. Benign nevus,
c. Chemical staining,
d. Normal variant in darkly pigmented people.

Splinter hemorrhage:
Longitudinal, thin, reddish lines occurring beneath the nail plate.

Found in:
a. Subacute bacterial endocarditis,
b. Systemic lupus erythematosus,
c. Rheumatoid arthritis,
d. Peptic ulcer disease,
e. Malignancies,
f. Oral contraceptive use,
g. Pregnancy,
h. Psoriasis,
i. Trauma.

Irregular, twisted and dilated vessels at the distal portion of cuticle covering the nail bed.

Found in:
a. Rheumatoid arthritis,
b. Systemic lupus erythematosus,
c. Dermatomyositis,
d. Scleroderma.

Longitudinal striations:
Found in:

a. Alopecia areata,
b. Vitiligo,
c. Atopic dermatitis,
d. Psoriasis.

Ashraful Emdad,
Army Medical College Cumilla,
Session: 2016-17.

Platform academic / Ariful Islam Neloy

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