Common nail changes and disorders in older people: Diagnosis and management

Lina Abdullah; Ossama Abbas

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Figure 1.
Anatomy of a nail unit
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Figure 2.
Mild brittle nails with mild longitudinal ridging and mild distal lamellar splitting
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Figure 3.
Onychauxis: Localized hypertrophy of the nail plate with discoloration and loss of nail plate translucency.
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Figure 4.
Distal and lateral subungual onychomycosis: Onycholysis, subungual hyperkeratosis, as well as nail thickening and discoloration.
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Figure 5.
superficial onychomycosis: White patchy discoloration of the dorsum of the nail plate.
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Figure 6.
Chronic paronychia: Red and swollen nail folds, cuticle loss, and secondary nail plate changes.
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Figure 7.
Subungual hematomas: Red to bluish subungual discoloration.
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Figure 8.
Longitudinal melanonychia: A longitudinal dark band can be a manifestation of melanocytic lesions, drugs, or Bowen disease, among other causes.
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Figure 9.
Longitudinal erythronychia: A longitudinal red band can rarely be a manifestation of Bowen disease.

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Table 1.

Common nail conditions in older people

CONDITION	CLINICAL PRESENTATION	MANAGEMENT	UNDERLYING FACTORS
Brittle nail syndrome5-8	Onychoschizia transverse splitting and lamellar splitting of the free edge and distal nail plate portion Onychorrhexis nail plate splitting or ridging triangular fragments at the free edge longitudinal thickening	Identify and correct any underlying factors Recommend nail hydration oral biotin	Repetitive wetting and drying cycles, trauma, cosmetics, systemic and dermatologic diseases
Onychauxis1^,2^,9	Discoloration, loss of nail plate translucency, subungual hyperkeratosis	Periodic debridement	Advancing age, faulty biomechanics
Onychoclavus1^,2	Tender dark area usually under the distal nail plate of the great toe	Surgical removal of hyperkeratotic tissue Correct any underlying bony abnormality	Chronic minor trauma, bony abnormalities
Onychomycosis1^,2^,10-16	DLSO subungual hyperkeratosis onycholysis nail thickening and discoloration Superficial onychomycosis patchy nail plate discoloration PSO white area under the lunula that progresses distally TDO progressive nail plate destruction with thickened nail bed	Recommend antifungal agents, mechanical or chemical treatments, or oral terbinafine (appears to be most effective) Generally, low success rate in the elderly	Dermatophytes, yeasts, or nondermatophyte molds
Paronychia1^,2^,17	Acute tender erythematous nail fold swelling Chronic red swollen nail folds, cuticle loss, secondary nail plate changes	Acute warm saline soaks abscess drainage antibiotics Chronic drying the nail fold topical antifungals or antiseptics	Acute Staphylococcus aureus Chronic Candida species or Gram-negative bacteria
Onychocryptosis1^,2^,18	Lateral nail fold inflammation, granulation tissue, secondary infection	Conservative management Partial nail avulsion and lateral matricectomy	Improper nail cutting, prominent nail folds, inappropriate shoes, bony abnormalities
Subungual hematomas1^,2	Painful red to bluish subungual discoloration that tends to move forward	Rule out melanoma Observation In acute painful cases, drill a hole in the nail plate	Usually trauma

DLSO—distal and lateral subungual onychomycosis, PSO—proximal subungual onychomycosis, TDO—total dystrophic onychomycosis.

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Table 2.

Nail changes due to common skin diseases

CONDITION	CHARACTERISTIC NAIL CHANGES
Psoriasis	Irregular large and deep nail pits Salmon patches (oil-drop sign) of the nail bed (yellow–orange discoloration) Onycholysis Might also have subungual hyperkeratosis, nail plate thickening, and splinter hemorrhages
Lichen planus	Nail thinning, ridging, and fissuring Dorsal pterygium (adhesion of the proximal nail fold to the nail bed)
Alopecia areata	Geometric small, superficial, and regularly distributed nail pits Erythema of the lunula
Darier disease	Longitudinal erythronychia Distal V-shaped nail plate nicking
Trachyonychia	Twenty-nail dystrophy Nail roughness and excessive longitudinal ridging Idiopathic but might be a manifestation of alopecia areata, psoriasis, or lichen planus

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Table 3.
Nail changes due to cosmetic material and procedures
FACTORS ASSOCIATED NAIL ADVERSE EFFECTS
Cosmetic material Irritant and allergic contact dermatitis
Nail plate staining
Cosmetic procedures Trauma and mechanical damage
Infections

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Table 4.

Selected important nail signs of systemic disease

NAIL SIGN	COMMONLY ASSOCIATED SYSTEMIC DISEASE
Koilonychia (flat- and spoon-shaped nail plate)	Severe iron deficiency anemia
Proximal splinter hemorrhages	Bacterial endocarditis Antiphospholipid syndrome Arterial emboli Thrombocytopenia Vasculitis Trichinosis
Apparent leukonychia (white nails, the colour of which fades with pressure)	Half and half nails (white proximal half) renal disorders Terry nails hepatic disorders, chronic congestive heart failure, and adult-onset diabetes mellitus Muehrcke lines (multiple transverse whitish bands) systemic chemotherapy and hypoalbuminemia
Ventral pterygium (adhesion of the distal nail plate to the hyponychium)	Scleroderma
Clubbing (enlarged and excessively curved nail plate, causing more than 180° widening of the angle between the proximal nail fold and the nail plate)	If unilateral, neurologic (hemiplegia) and vascular disorders If bilateral, pulmonary, cardiac, gastrointestinal, infectious, and endocrine diseases
Nail fold capillary abnormalities (reduced capillary density and avascular areas alternating with dilated capillary loops)	Dermatomyositis Scleroderma