Disorders Techniques in Investigation and Diagnosis - part 3 pps

Figure 3.2 Longitudinal lines in a patient with rheumatoid arthritis. Figure 3.3 Longitudinal lines—old age ‘sausage link’ appearance. Modifications of the nail surface 61 Figure 3.4 Longitudinal lines—prominent old age changes, which may occur earlier with chronic arterial impairment. Figure 3.5 Longitudinal dystrophy in lichen planus. A text atlas of nail disorders 62 Figure 3.6 Mild onychorrhexis in lichen planus. Figure 3.7 (a, b) Severe onychorrhexis and nail thinning in lichen planus. Modifications of the nail surface 63 Figure 3.8 Longitudinal nail groove due to (a) glomus tumour, (b) myxoid cyst, (c) fibrokeratoma. Figure 3.9 Myxoid cyst—longitudinal groove and Beau’s lines. A text atlas of nail disorders 64 Figure 3.10 Heller’s median canaliform dystrophy (Leclercq’s variant). Figure 3.11 Heller’s median canaliform dystrophy. Modifications of the nail surface 65 Figure 3.12 Onychotillomania—median nail dystrophy of several nails. Figure 3.13 Onychotillomania—severe median nail dystrophy of the thumb and third finger nail. Figure 3.14 Central longitudinal grooved dystrophy, self-induced by trauma to the matrix. A text atlas of nail disorders 66 Figure 3.15 Unilateral central longitudinal grooved dystrophy. Figure 3.16 Deep groove plus transverse lines—self-induced matrix trauma. Longitudinal ridges Small rectilinear projections extend from the proximal nail fold as far as the free edge o f the nail, or they may stop short. They may be interrupted at regular intervals, giving rise to a beaded appearance. Sometimes a wide, longitudinal median ridge has the appearance, in cross-section, of a circumflex accent. The condition is inherited an d affects mainly the thumb and index fingers of both hands. Table 3.1 shows the principal causes of longitudinal lines and grooves. Modifications of the nail surface 67 HERRINGBONE NAILS The pattern of nail ridging known as ‘herringbone nails’, with oblique lines pointing centrally to meet in the midline, has been reported as an uncommon phenomenon occurring in childhood (Figure 3.17). It characteristically disappears as the child grows. Less obvious, similar lines may be seen associated with the pointed matrix of the nail- patella syndrome. TRANSVERSE LINES Transverse, band-like depressions extending from one lateral edge of the nail to the other, and affecting all nails at corresponding levels, are called Beau’s lines (Figures 3.18 – 3.22). They may be noted after any severe, sudden (particularly febrile) illness. In milde r Table 3.1 Causes of longitudinal lines Coloured lines White See leukon y chia (pa g es 128–134) Black See melanonychia (pages 134–139) Red Darie r ’s disease (see Fi g ure 2.55) Vascular tumours Glomus (Figure 3.8) Cirsoid Linear rid g es Sin g le Familial Median canaliform d y stroph y (Fi g ure 3.10) Trauma (isolated or repeated) Tumours Multiple N ormal; increase with a g e after earl y adulthood (Fi g ures 3.1, 3.3, 3.4) With all causes of thin nail plates Lichen planus (Fi g ure 3.5) Rheumatoid arthritis Graft-versus-host disease Psoriasis Darie r ’s disease Poor circulation Colla g en vascular diseases Radiation Frostbite Alopecia areata N ail- p atella s y ndrome S y stemic am y loidosis A text atlas of nail disorders 68 cases the nails of the thumb and the great toe are the most reliable markers, as the forme r supplies information for the previous 6–9 months and the latter shows evidence o f disease for up to 2 years (relating to the different rates of linear nail growth). The width of the transverse groove relates to the duration of the disease that has affected the matrix. The distal limit of the furrow, if abrupt, indicates a sudden attack o f disease; if sloping, a more protracted onset. The proximal limit of the depression may be abrupt, and both limits may well be sloped. If the the disease can completely inhibit the activity of the matrix for 1–2 weeks or longer, the transverse depression will result in total division of the nail plate, a defect known as ‘onychomadesis’ (Figures 3.23, 3.24). As the nail adheres firmly to the nail bed the onychomadesis remains latent for several weeks before leading to temporary shedding. Figure 3.17 (a) Herringbone nail appearance with oblique lines meeting in the midline—a temporary change of early childhood; (b) nail-patella syndrome—more subtle, but similar lines to (a); associated with pointed lunula. (Part (a) from Parry EJ, Morley WN, Dawber RPR (1995), Herringbone nails: an uncommon variant of nail growth in childhood? Br J Dermatol 132: 1021–1022.) T he presence of Beau’s lines on all 20 nails is usually the result of systemic disease Modifications of the nail surface 69 Figure 3.18 Beau’s lines. Figure 3.19 Beau’s lines—contact dermatitis. Transverse furrows may be due to measles in childhood, zinc deficiency (often multiple), Stevens-Johnson and Lyell’s syndromes, cytotoxic drugs and many other non- specific events. Beau’s lines can also be physiological, e.g. marks appearing with each menstrual cycle, particularly in dysmenorrhoea. They have also been noted in babies aged 4–5 weeks, without any obvious cause. When only a few digits are involved this may indicate trauma, carpal tunnel syndrome, chronic paronychia or chronic eczema. If the lines appear following a chronic condition, they are often numerous and curvilinear. A text atlas of nail disorders 70 [...]... nail involvement (idiopathic trachyonychia) Figure 3. 32 Trachyonychia (rough nails) due to alopecia areata A text atlas of nail disorders Figure 3. 33 Trachyonychia—shiny variety Figure 3. 34 Trachyonychia—idiopathic 78 Modifications of the nail surface 79 Figure 3. 35 Trachyonychia—involvement of a single nail Figure 3. 36 Trachyonychia in a manual worker Figure 3. 37 Trachyonychia—lichen planus Twenty-nail... Bleomycin, docetaxel, doxorubicin, fluorouracil, retinoids, captopril, paclitaxel, mitozantrone Drug-induced photo-onycholysis: trypaflavin, chlorpromazine, chloramphenicol, A text atlas of nail disorders 92 cephaloridine, icodextrin, clorazepate dipotassium, allopurinol, cloxacillin (exceptional), tetracyclines: especially demethylchlortetracycline and doxycycline, also minocycline, fluoroquinolones,... amyloidosis has been reported in X-linked dominant chondrodysplasia punctata and in polycythaemia vera It may be seen in the proximal portion of the nail in lichen planus (Figure 3. 41), and also as a result of oral retinoid therapy (Figures 3. 43, 3. 44) The term ‘elkonyxis’ indicates proximal onychoschizia that is especially seen in patients taking oral retinoids Table 3. 5 lists the known causes of... hydration and dehydration of the nails Onychoschizia ‘Layering’ in the diastal portion of the finger nail is usually due to frequent wetting Figure 3. 39 Onychoschizia (lamellar splitting or layering) Figure 3. 41 Onychoschizia and onychorrhexis due to lichen planus Modifications of the nail surface 83 Figure 3. 40 Onychoschizia lamellina affecting several finger nails Figure 3. 42 Onychoschizia and onychorrhexis... of nail disorders 90 Figure 4.5 Photo-onycholysis Figure 4.6 Self-induced onycholysis • Type I: several fingers are involved; the separating part of the nail plate is halfmoon-shaped and concave distally with a pigmentation of variable intensity, and shows a well-demarcated proximal border • Type II: one finger only is affected; a well-defined circular notch is present, which opens distally and has... especially in psoriasis The accumulation of large amounts of serum-like exudate containing glycoprotein, in and under the affected nails, explains the colour change in this condition Glycoprotein is also commonly found in Figure 4.2 Onycholysis with Pseudomonas aeruginosa discoloration Nail plate and soft tissue abnormalities 89 Figure 4 .3 Onycholysis—showing the separation of the nail plate and nail... Figure 3. 31 Multiple nail pits—‘rippled’ effect in alopecia areata Table 3. 3 lists the causes of nail pitting TRACHYONYCHIA (ROUGH NAILS) The term ‘twenty-nail dystrophy’ or trachyonychia describes a spectrum of nail plate surface abnormalities that result in nail roughness (Figures 3. 32 3. 38) Patients with trachyonychia can be divided into two main groups: 1 Trachyonychia and a past history or clinical... some cases a genetic basis is thought likely In secondary syphilis and pityriasis rosea pitting occurs rarely One case of the latter has been observed with the pits distributed on all the finger nails at corresponding levels, analogous to Beau’s lines Table 3. 3 Causes of pitting Common Psoriasis (Figures 3. 26, 3. 27, 3. 29, 3. 30) Alopecia areata (Figure 3. 31) Eczema Occupational trauma Parakeratosis... arranged in series along one or several longitudinal lines; they are sometimes arranged in a criss-cross pattern and may resemble the external surface of a thimble A text atlas of nail disorders Figure 3. 25 Pit formation Figure 3. 26 Multiple nail pits, arranged in transverse lines 74 Modifications of the nail surface 75 Figure 3. 27 Multiple nail pits—similar to Figure 3. 26, but more lined in appearance... attributed to psoriasis, and profuse pitting is most often due to this condition (Figures 3. 29, 3. 30) In alopecia areata (Figure 3. 31) shallow pits are usually seen and they are often numerous, leading to trachyonychia (rough nail) and twenty-nail dystrophy; however, curiously, one nail often remains unaffected for a long time, Pits may also occur in eczema or occupational trauma In some cases a genetic . is inherited an d affects mainly the thumb and index fingers of both hands. Table 3. 1 shows the principal causes of longitudinal lines and grooves. Modifications of the nail surface 67 HERRINGBONE. corresponding levels, analogous to Beau’s lines. Table 3. 3 Causes of pitting Common Psoriasis (Fi g ures 3. 26, 3. 27, 3. 29, 3. 30) Alopecia areata (Fi g ure 3. 31) Eczema Occupational trauma. Figure 3. 34 Trachyonychia—idiopathic. A text atlas of nail disorders 78 Figure 3. 35 Trachyonychia—involvement of a single nail. Figure 3. 36 Trachyonychia in a manual worker. Figure 3. 37