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Probability diagnosis

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Fungal infection: onychomycosis

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Onycholysis:

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  • trauma to nail bed

  • trauma from biting

  • trauma from habit picking

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Onychogryphosis

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Paronychia

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Psoriasis

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Serious disorders not to be missed

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Melanoma

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Iron deficiency: koilonychia

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Liver disease: leuconychia

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Endocarditis: splinter haemorrhages

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Chronic kidney failure: white bands, half-and-half nail

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Glomus tumour

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Bowen disorder/squamous cell carcinoma

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Pitfalls (often missed)

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Atopic dermatitis (pitted nails)

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Lichen planus

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Pyogenic granuloma (usually with ingrowing toenails)

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Drug effects (e.g. tetracycline)

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Pseudomonas infection

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Connective tissue disorders (e.g. SLE)

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Arsenic (Mees stripes)

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Is the patient trying to tell me something?

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Consider onychotillomania, where patients pick and self-mutilate their nails, resulting in parallel transverse grooves (washboard deformity or habit-tic nails).

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Key history

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Enquire about a history of severe stress or illness and possible onychotillomania, be it excessive nail biting, picking or cleaning. Ask whether the hands are frequently in wet work (e.g. dishwashing, soaps and detergents) or dirt.

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Key examination

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Careful examination of nails: look for associated skin disease (e.g. psoriasis, atopic dermatitis, tinea pedis, lichen planus)

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Key investigations

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  • Nail clippings for culture and histology

  • FBE and ESR

  • Consider LFTs and CXR

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Diagnostic tips

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  • Clubbing is an abnormality of the fingertips rather than nails.

  • Crumbly white nails are not always caused by fungus.

  • Skin disorders that can involve nails include atopic dermatitis, psoriasis, epidermolysis bullosa, exfoliative dermatitis and lichen planus.

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