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Lifting of the nail plate (onycholysis)
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Trauma
Factitious (self-induced)
Tinea
Psoriasis
Photosensitivity, usually tetracyclines
Others (e.g. warts, lichen planus)
Hyperthyroidism
Nail destruction:
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Thickening of the nail plate
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Thinning of the nail plate
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Trauma—wear and tear (repeated water immersion)
Artificial fingernails—application and removal
Lichen planus
Peripheral vascular disease (impaired peripheral circulation)
Twenty-nail dystrophy, usually children
Brittle nails
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Pitting of the nail plate
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Psoriasis
Alopecia areata
Atopic dermatitis
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Longitudinal marks in the nail plate
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Myxoid cyst
Angiofibroma
Ageing
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Causes (central single stripe)
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Darier disease
Hereditary/congenital
Mechanical trauma
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Horizontal grooves in nail plate
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Horizontal single white lines or band
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Chemotherapy
Arsenic poisoning
Kidney failure
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Lamellar splitting (onychoschizia)
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Spoon nails: koilonychia
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Hereditary/congenital
Lung disease (e.g. cancer, pulmonary fibrosis, sepsis)
Heart disease (e.g. congenital cyanotic, SBE)
Liver disease (e.g. cirrhosis)
Gastrointestinal disorders (e.g. Crohn disease)
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Splinter haemorrhages
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Discolouration of the nail plate
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Swelling of the proximal nail folds (paronychia)
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Swelling of the lateral nail folds
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Tumours of the nail fold
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myxoid (mucus) cyst
warts
periungual fibroma
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squamous cell carcinoma
melanoma
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Destruction of the nail apparatus
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Trauma
Lichen planus
Melanoma
Bowen disease
Squamous cell carcinoma
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Onycholysis refers to the separation of the nail plate from the underlying nail bed and is a sign rather than a disease. This separation creates a subungual space with an air interface that gathers unwanted debris, such as dirt and keratin. It is usually seen in fingernails but it can develop in toenails from rubbing against shoes. Adverse local reactions to agents such as formaldehyde and resins in polishes or nail glues can distort nails.
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Self-induced trauma is a common cause from obsessive manipulation, including meticulous cleaning and frequent manicuring.
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The band of discolouration at the end of the separated nail is usually in a straight line compared with other causes such as psoriasis and tinea. Tinea may be distinguished from other causes by white or yellow streaks or ‘spears’ travelling proximally in the nail.
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Greenish discolouration indicates invasion by Pseudomonas pyocyanea or Aspergillus.
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First exclude psoriasis, tinea (check toe webbing) and trauma (check history).
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Keep nails as short as possible
Avoid insertion of sharp objects under nails for cleaning out debris
Apply tape (Micropore or similar) over free edge for months, until healed
Avoid unnecessary soaps and detergents—wear gloves for housework, gardening, etc.
Keep hands out of water
Use a mild soap and shampoo
First-line treatment especially if mild infection is white vinegar soaks, diluted 1:1 with water—10 minutes two times daily for 3–4 weeks.6
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Pharmaceutical treatment
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Daily application of an imidazole (e.g. clotrimazole) or terbinafine
Potent topical corticosteroids in lotion form may be useful
For Pseudomonas infection soak the nails in vinegar or Milton’s solution and/or gentamicin sulphate cream
If Candida albicans confirmed, best to use oral treatment, e.g. fluconazole or itraconazole6
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Refer difficult and unresponsive cases to a dermatologist.
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Psoriasis can have many manifestations, such as pitting, onycholysis, discolouration, splinter haemorrhages, distal subungual hyperkeratosis (which can resemble warts) and severe total nail dystrophy (often with arthropathy). Psoriasis can closely mimic onychomycosis, which should be excluded by fungal culture and histology before commencing presumed tinea therapy.
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There is no effective topical therapy for psoriasis of the nails but a trial of a potent corticosteroid lotion may help selected cases. Intralesional steroid injections, which are painful and require multiple treatments, can help. Successful treatment of the skin does not help the nails.
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Onychomycosis (fungal nail infection)
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Key facts and checkpoints
Affects 3–5% of population and 40% over 60 years1
Classified as superficial, distal or proximal
Toenails affected more commonly than fingernails
The most common form is distal lateral subungual caused by Trichophyton mentagrophytes var. interdigitale (typical of toe web space tinea and responds well to terbinafine) or by Trichophyton rubrum (common on sole of foot and more resistant)
Superficial white onychomycosis is also common, and is usually confined to the toenails with small superficial white plaques with distinct edges and caused by Trichophyton mentagrophytes var. interdigitale
Total dystrophic onychomycosis—whole nail affected, thickened, opaque and yellow brown (caused by Trichophyton sp.)
Candida albicans and other fungi are not a common factor
Diagnosis—always confirm by culture and histology of the distal nail plate clippings placed in formalin. Positive in 60–80% of cases
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In most cases it is not a major clinical problem and no treatment is a reasonable plan. Regular nail clipping is important. The antifungal treatment of choice for all types of toenail tinea is:
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An alternative is itraconazole 200 mg (o) bd for the first week of each month for 2 months for fingernails; 3–4 months for toenails.
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No improvement apart from the proximal part of the nail will be noticed after months because it takes 12 months or more for the toenail to grow.
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Mark the base of the dystrophic nail with a scalpel blade or black ink to assess progress.
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Topical treatment for superficial or distal nail involvement7
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amorolfine 5% (Loceryl) nail lacquer 1–2 times weekly after filing (fingernails: 6 months; toenails: 9–12 months)
or
miconazole tincture daily until resolution
or
ciclopirox lacquer daily until resolution
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A systematic review found poor evidence for the effectiveness of topical therapy for onychomycosis.8
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Consider twice-daily applications of tea-tree oil indefinitely for tinea pedis and tinea unguium.
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This is a painful condition that is mainly due to bacterial infection, especially Staphylococcus aureus.
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Uncomplicated with localised pus:
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simple elevation of nail fold or puncture the fold—close to drain pus
advice on hygiene
antibiotics not usually necessary
if not responding to drainage, use (di)flucloxacillin
exclude diabetes
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Complicated with subungual extension:
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Excessive manipulation of cuticles (e.g. by manicurists)
Occupational (e.g. chefs, housewives, nurses, fishmongers)
Frequent contact with water, detergents and chemicals
Habit tic—picking the nail fold
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Culture organisms
Exclude diabetes
Basic nail care advice:
– keep hands dry (avoid wet work if possible)
– wear cotton-lined gloves when washing dishes (for max. of 15 minutes)
– minimise contact with water, soap, detergents, lipid solvents and other irritants
– never pick, push back or manicure cuticles
– never insert anything beneath cuticle for cleaning
– wear cotton gloves in garden
– use a mild soap and shampoo
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For Candida (if cultured):
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For Staphylococcus (if cultured):
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Topical medications to nail folds (especially if persistent exudate):
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Vaseline (to waterproof) can be applied frequently (5–10 times daily) when it is dry and without exudate.
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Very potent topical corticosteroids are helpful. Refer unresponsive cases.