Bolognia.68.71.nails.ms

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nail unit anatomy

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Embryologic development of the nail apparatus.

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nail apparatus

Front 4

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Onychomadesis after an episode of acute paronychia

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Nail pitting due to psoriasis.

Front 6

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Trachyonychia (twenty-nail dystrophy). The nails seem sandpapered in a longitudinal direction

Front 7

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Longitudinal melanonychia due to a congenital melanocytic nevus of the nail matrix. The pigmentation involves approximately 75% of the nail plate and the color varies from light brown to black

Front 8

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Congenital malalignment of the great toenails. The longitudinal axis of the nail plate is deviated laterally. There is also onychomadesis of both great toenails and mild nail thickening with lateral ingrowing of the right great toenail.

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Nail hypoplasia in nail–patella syndrome. There is hypoplasia of the nails of the first and second digits. This gradient of severity of nail involvement is characteristic

Front 10

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Darier disease. Alternating longitudinal red and white streaks with wedge-shaped subungual hyperkeratosis, V-shaped notching of the distal margin, and fissuring. *G

Front 11

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Nail psoriasis. The nails show salmon patches (“oil drop” changes) and onycholysis with an erythematous border

Front 12

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Acrodermatitis continua of Hallopeau. Recurrent pustular eruption of the nail bed and distal finger.

Front 13

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Nail lichen planus. Note the nail thinning with longitudinal ridging and fissuring

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Yellow nail syndrome. Note the overcurvature of the nail and loss of the cuticle, in addition to the yellow discoloration.

Front 15

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Muehrcke’s nails. There are multiple parallel transverse white bands. The curvature matches that of the lunula......seen in nephrotic syndrome and low albumin states

Front 16

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Multiple periungual pyogenic granulomas in a patient taking indinavir

Front 17

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Acute paronychia. In addition to the erythema and purulent discharge, there is significant tenderness.

Front 18

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Median canaliform dystrophy (of Heller)

Front 19

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Subungual exostosis

Front 20

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Correlation of nail findings with anatomic site of nail damage

Front 21

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Myxoid cyst. The longitudinal nail groove is a result of the compression of the nail matrix by the cyst.

Front 22

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Onychomatricoma. The nail is thickened and overcurved with longitudinal yellow streaks. The distal border shows several holes

Front 23

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Bowen’s disease. The lateral portion of the nail plate is absent. The nail bed shows hyperkeratosis with scaling and fissuring of the epithelium

Front 24

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Amelanotic melanoma. Note the diffuse nail destruction and ulceration

Front 25

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Back 25

ABCDEF rule for clinical suspicion of nail melanoma

Front 26

What layers is the nail plate made of?

Back 26

1. outer dorsal plate
2. intermediate plate (multiple desmosomes)
3. ventral plate (high content of soft keratins)

Front 27

What is the growth rate for fingernails?*G

Back 27

2-3mm/mo.....6mo needed for total replacement

Front 28

What is the growth rate for toenails?*G

Back 28

1mm/mo.....12-18mo for total replacement

Front 29

what do we call the thin white transverse line at the free edge of the nail plate?

Back 29

onychocorneal band

Front 30

What does the proximal nail matrix form?

Back 30

-dorsal plate

Front 31

What does the distal matrix (lunula) form?

Back 31

intermediate and ventral plate

Front 32

Where are the melanocytes associated with the nail?

Back 32

in the distal nail matrix and suprabasal layers......think melanocytes should be farther from the body

Front 33

In someone with light skin, what do you do if there is nail plate pigment?

Back 33

requires bx, cause their melanocytes sould be dormant and contain pre and stage I/II melanosomes, NOT mature melanosomes

Front 34

Which keratins are found in the proximal nail matrix?

Back 34

soft keratins (1, 5, 6, 10, 14, 16, 17)

Front 35

Which keratins are found in the distal nail matrix?

Back 35

soft keratins (1,5,10,14,20)
hard keratins (31)

Front 36

which Ag medites nail plate attachment to the nail bed?

Back 36

CEACAM1

Front 37

What infection can occur with nail infections?

Back 37

OM (high risk)....cause collagen fibers in the dermis radiate into the distal phalangeal bone

Front 38

Where do we see AV anastomoses?

Back 38

everywhere except the proximal nail fold

Front 39

What is the underlying abnormality with Beau's lines?

Back 39

abnormal matrix function...there is interruption of mitotic activity of the proximal nail matrix

Front 40

What does depth of the beau's line mean? What about width?

Back 40

Depth: extent of damage....same level in multiple digits suggests systemic disease
Width: duration of damage

Front 41

What is the most common cause of Beau's lines?

Back 41

trauma is MC

Others:
eczema
chronic paronychia
derm dz that affect proximal nail fold

Front 42

What is the underlying abnormality in onychomadesis?

Back 42

-there is complete arrest of nail matrix activity -resulting in proximal detachment from proximal nail fold

Front 43

What is the underlying abnormality in nail pitting?

Back 43

-proximal nail matrix damage
-it results in foci of abnormal keratiniziation with clusters of parakeratosis that falls off the dorsal nail plate

Front 44

What do we call longitudinal ridging, fissuring and thinning of nail plate?

Back 44

onychorrhexis

can be associated with LP, or a normal part of aging.

Front 45

What do we call sandpapered nails? And what is the pathophys?

Back 45

trachyonychia....due to proximal nail matrix damage

Front 46

What is the pathophys behind true leukonychia?

Back 46

there is white opaque discoloration due to abnormal nail matrix (distal) keratinization with resultant parakeratotic cells in the ventral nail plate

Front 47

Who gets punctate leukonychia?

Back 47

kids, likely due to trauma

Front 48

Who gets striate leukonychia? And what are common causes

Back 48

AKA Mee's lines
-adults, commonly women
-can be secondary to trauma from manicures or from shoes
-arsenic or thallium poisoning
-chemotherapeutic agents

Front 49

What do we call spoon shaped nails (concave)?

Back 49

koilonychia

Front 50

What causes koikonychia?

Back 50

-physiologic in the toenails of kids
-can be occupational or "iron def" in adults
-thyroid abnormalities

Front 51

What are causes of photo-onycholysis?

Back 51

-tetracyclins
-psoralens
-NSAIDs

Front 52

What do we call nail plate thickening due to subungal hyperkeratosis?

Back 52

onychauxis
-it is a nail bed problem

Front 53

What are common causes of onychauxis?

Back 53

psoriasis
onychomycosis
eczema

Front 54

What is apparent leukonychia?

Back 54

white discoloration of the nails that fades with pressure because it is due to nail bed edema, not a nail plate issue

Front 55

What are causes of apparent leukonychia?

Back 55

-chemo agents
-systemic disease (hypoalbuminemia)

Front 56

What is the cause of splinter hemorrhages?

Back 56

damage to longitudinally oriented nail bed capillaries

Front 57

What causes green nail syndrome?

Back 57

the greenish black/blue discoloration is due to Pyocyanin produced by pseduomonas

Front 58

What's the most common cause of ingrown toenails?

Back 58

congenital malalignment of the big toenails (lateral deviation of the nail plate)

Front 59

What do we call short, broad thumbnails due to shortening of the distal phalynx?

Back 59

raquet thumbs (brachyonychia)....AD inheritance

Front 60

What are the features of Nail-Patella Syndrome (Hereditary osteo-onychodysplasia)?

Back 60

-absent or hypoplastic nails
-triangle shaped lunulae
-bony abnormalities (absent or hypoplastic patellae, radial head dysplasia and iliac cres exostoses/horns)

Front 61

How can you confirm the dx of nail-patella syndrome?

Back 61

iliac horns on pelvic xray in kids

Front 62

What is the mutation in nail patella syndrome?

Back 62

LMX1B....it codes for a transcription factor that regulates collagen synthesis

Front 63

What changes are seen in the nails of those with EB?

Back 63

-repeated blisters produce onycholysis with shortening/thickening of the nail (due to nail bed scarring)
-nail matrix involvement results in nail thinning, atrophy, pterygium

Front 64

What nail changes are seen with pachyonychia congenita?

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-thickened and extremely hard nails with increased transverse curvature due to severe nail bed hyperkeratosis
-hyperkeratosis

Associated findings: palmoplantar keratoderma, follicular hyperkeratosis

Front 65

What are the mutations in type I pachyonychia congenita?

Back 65

KRT6a and KRT16

Front 66

What are the mutations in type II pachyonychia congenita?

Back 66

KRT6b and KRT17

Front 67

Which type of pachyonychia is associated with oral leukokeratosis?

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type I

Front 68

Which type of pachyonychia is associated with premature dentition and pilosebaceous cysts?

Back 68

type II

Front 69

What nail changes are seen in Darier Disease?

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-multiple red and white longitudinal streaks within the nail plate with MNG cells in the nail bed epithelium
-distal wedge shaped subungal hyperkeratosis plus fissuring corresponding to the bands
-V shaped indentation of the distal margin
-single red band (longitudinal erythronychia) due to benign subungal tumor (onychopapilloma)

*nail changes don't improve with oral retinoids
*similar nail changes in Hailey Haiely

Front 70

What is the ddx for red lunula?

Back 70

-alopecia areata
-psoriasis
-SLE, RA
-medial disease (cardiac, COPD, cirrhosis)
-drugs and toxins (imuran, radiation, prednisone, CO2/**CO poisoning)

Front 71

What are the diagnostic nail changes seen with psoriasis?

Back 71

-irregular pitting
-salmon patches (oil drop)
-onycholysis with erythematous border

Front 72

How can we treat psoriatic nail changes?

Back 72

-IL kenalog
-oral acitretin

Front 73

What are the nail changes seen in acrodermatitis continua of Hallopeau?

Back 73

-pustules involving the nail bed and periungal skin
-fingernails most commonly affected

*seen in those with palmoplantar psoriasis

Front 74

What are the nail changes seen in parakeratosis pustulosa and who gets them?

Back 74

-seen exclusively in kids
-usually one fingernail, often one side of the nail
-there is subungal hyperkeratosis and onycholysis, this is preceded by erythema, scaling and vesicles of the fingertip

Front 75

What are the nail changes with LP?

Back 75

-thinning
-onychorrhexis
-ridging
-**dorsal pterygium
-can have 20 nail disease

Front 76

What does pterygium in nail LP indicate?

Back 76

scarring

Front 77

How to treat nail LP?

Back 77

-IL kenalog (when few nails involved)
-systemic steroids to avoid pterygium

Front 78

What are causes of 20 nail dystrophy (trachyonychia)?

Back 78

-alopecia areata (seen in 12% of kids vs. 3% of adults)
-LP
-psoriasis, eczema
-idiopathic (uncommon and almost exclusively in kids)

Front 79

What nail findings are seen with alopecia areata?

Back 79

-geometric pitting
-trachyonychia....more common in kids and seen in those with totalis/universalis
-other findings:erythema of lunula, punctate leukonychia, onychomadesis

Front 80

What nail changes are seen in eczema?

Back 80

-Acutely: vesicles/erythema of the proximal nail fold and hyponychium, irregular pits, Beau's lines
-Chronically: localized to hyponychium, subungal hyperkeratosis, onycholysis, fissuring of hyponychium

Front 81

What is the lovibond angle? And in what disease is it widened?

Back 81

-formed by the proximal nail fold and the nail plate
-widened in clubbing

Normal= 160, in clubbing it is 180

Front 82

What is yellow nail syndrome?

Back 82

-arrested linear nail growth resulting in transverse thickening and overcurving longitudinally
-cuticle is absent
-onycholysis and nail shedding is often seen

Front 83

What systemic conditions are associated with yellow nail syndrome?

Back 83

-lymphedema
-resp tract involvement (chronic bronchitis, pleural effusions)

Front 84

How to treat yellow nail syndrome?

Back 84

Vit D
itraconazole (can accelerate growth)

Front 85

What's the most common tumor that metastasizes to fingers?

Back 85

lung

Front 86

What's the most common tumor that metastasizes to toes?

Back 86

GU neoplasms

Front 87

What can transient peripheral nerve injury cause at the level of the nails?

Back 87

-onychomadesis
-pseudopyogenic granulomas of the proximal nail fold
-often seen after cast immobilization
-resolves over wks

Front 88

What is ventral pterygium a sign of?

Back 88

scleroderma, related to impaired peripheral perfusion (the distal nail plate adheres to the hyponychium)

Front 89

What are nail changes seen with HIV infection?

Back 89

-proximal subungal onychomycosis due to T. rubrum
-candida onychomycosis (which indicates immunosuppression)
-chronic periungal warts

Front 90

If an HIV+ patient has chronic periungal warts, what is the next step in management?

Back 90

biopsy to rule out SCC....HPV types 16 and 35 have been detected in such lesions

Front 91

What studies are mandatory with acute paronychia and what is usually found?

Back 91

-viral/bacterial cultures
-commonly S. aureus or Strep pyogenes
-can also be recurrent herpetic whitlow

Front 92

What is a good tx for warts around the nail?

Back 92

IL candida, trichophyton or mumps skin test Ag

Front 93

What is onychoschizia?

Back 93

-dehydration of the nail plate often due to frequent hand washing (the wet/dry cycles)
-there is splitting of the distal nail plate into multiple horizontal layers

Front 94

What secondary infections can be seen with chronic paronychia?

Back 94

candida or pseudomonas or TB

Front 95

What is onychotillomania?

Back 95

-aka habit tic deformity/chronic nail picking
-cuticle absent and proximal nail fold inflamed
-there is a longitudinal central depression

Front 96

What is another name for onychogryphosis? And who gets it?

Back 96

-ram's horn nails
-seen in elderly due to chronic trauma and impaired circulation/innervation

Front 97

What test is done with pincer nails?

Back 97

xray to exclude subungal exostosis....surgery is needed if this is present

-pain can be very severe

Front 98

How do we treat pincer nails?

Back 98

lateral matricectomy

Front 99

What is the formal name for ingrown toenail?

Back 99

onychocryptosis

Front 100

What are causes of periungal/subungal pyogenic granulomas?

Back 100

-penetrating trauma (including piercings)
-ingrown toenails
-systemic retinoids
-antiretrovirals
-EGFR inhibitors
-OCPs

Front 101

What do we call pink or skin colored papules originating from the proximal nail fold?

Back 101

fibromas/fibrokeratomas....aka Koenen tumor, seen in 50% of those with tuberous sclerosis

-they CAN produce a nail furrow

Front 102

What is the most common benign bony proliferation associated with nail abnormalities?

Back 102

subungal exostosis, most common is on the hallux
-it is a subungal nodule that elevates the nail plate
-confirm with xray

Front 103

What is the most common nail tumor?

Back 103

myxoid cysts (mucous cysts)

Front 104

What is a frequent association with myxoid cysts?

Back 104

Osteo arthritis of the DIP due to connection to DIP via a tract

Front 105

Patient has a tender red/bluish nail bed macule visible through the transparent nail plate, what is is?*G

Back 105

glomus tumor

Front 106

Patient has localized thickening of the nail plate with perforations consisting of multiple longitudinal hollows, what is the dx?

Back 106

onychomatricoma
-there can be multiple splinter hemorrhages
-frontal view shows holes in the thickened free margin

Front 107

What changes to the nail can be seen with melanocytic nevi of the nail matrix?

Back 107

longitudinal melonychia

Front 108

What factors can predispose to Bowen's disease of the nail?

Back 108

HPV 16
chronic Xray exposure

Front 109

What is a complication of subungal keratoacanthoma?

Back 109

-deep invasion with bone destruction
-does not regress spontaneously like cutaneous KA

Front 110

What is the most frequent malignant tumor of the nail apparatus?

Back 110

SCC

Front 111

What is the ABCDEF RULE related to nail MM?

Back 111

o Age (5-7th decade), African-Americans, Asians, and Native Americans (1/3 of nail MM)
o Brown to black, Breadth (3mm or wider), variegated Borders
o Change in nail band Color or size, lack of change in nail morphology despite presumed adequate treatment
o Digit most commonly involved (thumb and hallux)
o Extension of pigment into proximal or lateral nailfold (Hutchinson’s sign)
o Family or personal history of DN or MM

Front 112

Patient has a smooth soft nodule adjacent to the DIP. If at the proximal nail fold, it can cause longitudinal gooving int he nail plate. It contains clear yellow viscous fluid. What is the dx?*G

Back 112

myxoid cyst

Front 113

How do we distinguish acquired digital fibrokeratoma from accessory digit on path?*G

Back 113

ADF does NOT have nerves while AD does have prominent nerve fasicles

Front 114

What are some causes of absent lunula?*G

Back 114

yellow nail syndrome
multiple myeloma

Front 115

What is the formal name for short nails?*G

Back 115

brachyonychia

Front 116

What is the mutation in Darier's?*G

Back 116

SERCA2, a Ca ATPase

Front 117

What is the formal name for long nails?*G

Back 117

dolichonychia
-seen in Marfan's or Ehler's Danlos

Front 118

What is elkonyxis?*G

Back 118

large 2-3m pits

Front 119

How to distinguish habit tic from Heller median canaliform dystrophy?

Back 119

Habit tic: horizontal parallel ridges
Heller: christmas tree pattern to lines

Front 120

What is a heloma?

Back 120

corn

Front 121

What are lindsay's nails? And in what condition is it seen?*G

Back 121

distal nail is normal while proximal nail is white....seen in chronic renal failure.

*half and half cause you have 2 kidneys

Front 122

What is onychia?

Back 122

inflammation of the nail unit

Front 123

what is onychoclavus?

Back 123

subungal corn

Front 124

what is onychocryptosis?

Back 124

ingrown nail +/- exuberant granulation tissue, usually in the first toe

Front 125

What are causes of onychomadesis?

Back 125

-systemic disease
-PCN allergy
-syphillis
-psoriasis
-TEN/SJS
-pemphigus
-radiation
-drugs (chemo agents, carbamazepime, lithium)

Front 126

What is onychophagia?

Back 126

nail biting

Front 127

what is onychoptosis?

Back 127

nail loss

Front 128

What are plummer's nails?

Back 128

distal onycholysis secondary to hypothyroidism

Front 129

What are Terry's nails?

Back 129

all but distal 2mm evenly white, caused by problem in nail bed.
Caused by *cirrhosis, congenital heart failure, DM

""the liver is big so Terry's takes up most of the nail plate.

Front 130

What meds can cause yellow nail syndrome?

Back 130

D-penicillamine
bucillamine

Front 131

What is the most common organism in distal subungal onychomycosis?*G

Back 131

T rubrum

Front 132

What is the most common organism in white superficial/proximal subungal onychomycosis?*G

Back 132

T rubrum (HIV pts and kids)

Front 133

What is the most common organism in superficial onychomycosis?*G

Back 133

T mentag

Front 134

What is the most common organism in lateral invasion + paronychia onychomycosis?*G

Back 134

hendersonula toruloidea
scatylidium hyalinum

Front 135

mooshi is fluffy

Back 135

whhaaat

Front 136

what factors affect nail growth?

Back 136

accelerated: youth, daytime, summer, pregnancy, hyperthyroidism, psoriasis, PRP, itraconazole
Reduced: elderly, nightime, winter, fever, malnutrition, onychomycosis

Front 137

what type of epithelium is seen with the nail matrix?

Back 137

keratinizing epithelium, NO granular layer

Front 138

what part of the nail has a higher risk of osteomyelitis?

Back 138

the proximal nail matrix, it has diminished immune regulation similar to the hair follicle

Front 139

what causes splinter hemorrhages from a anatomic perspective?

Back 139

damage to the longitudinal capillaries in the dermis of the nail

Front 140

what are glomus bodies?

Back 140

encapsulated oval structures with tortuous vessels, nerves, and a capsule formed by cholinergic muscle cells and cholinergic nerves

*they dilate with cold to maintain digital blood supply
*they are found mostly in the dermis beneath the nail bed

Front 141

in what diseases do you see nail pitting?

Back 141

psoriasis
AA
eczema

Front 142

what is elkonyxis?

Back 142

large 2mm pits in the nail

Front 143

what is hapalonychia?

Back 143

soft nail plate

Front 144

who can get trachyonychia?

Back 144

those with:
LP
psoriasis
eczema
areata

Front 145

what causes diffuse leukonychia?

Back 145

chemo
white superficial onychomycosis
congenital disease

Front 146

what causes distal splinter hemorrhages?

Back 146

fungus, psoriasis, trauma

Front 147

what causes proximal splinter hemorrhages?

Back 147

trichinosis, vasculitis, carditis

Front 148

what genoderm has melonychia?

Back 148

laugier hunziker

Front 149

what do we call the nail finding of ridges that arise from the proximal nail fold and converge in a V shaped pattern distally?

Back 149

Chevron or Herringbone nail

Front 150

in what diseases can you see dorsal pterygium?

Back 150

LP
EB
TEN
GVHD
cicatricial pemphigoid

Front 151

which genoderm has brachyonychia?

Back 151

Rubenstein Taybi

Front 152

which conditions have absent lunulae?

Back 152

yellow nail syndrome and renal failure

Front 153

what causes Muehrcke's nails?

Back 153

hypoalbuminemia (nephrotic syndrome)
-you get transverse white bands

Front 154

In what disease do you see reduced capillary density with avascular areas alternating with dilated capillary loops in the cuticle?

Back 154

DM And scleroderma

Front 155

which chemo agents cause apparant leukonychia (Muercke's)?

Back 155

anthracyclines
vincristine

Front 156

which meds can cause melonychia?

Back 156

-chemoagents (doxorubicin, daunorubicin, 5-FU)
-Psoralens
-zidovudine (AZT)

Front 157

which meds have been indicated in ischemic changes of the nail/fingers?

Back 157

beta blockers
bleomycin

Front 158

what is platyonychia?

Back 158

flat nail (can be inherited or acquired)

Front 159

patient has a tumor of the nail which is aggrevated by physical and thermal stimuli (cold eesp), dx?

Back 159

glomus tumor

Front 160

what gives rise to the glomus tumor?

Back 160

the neuromyoarterial glomus cells of the nail bed dermis

Front 161

what causes blue lunulae?

Back 161

wilson's
drugs
PUVA
argyria

Front 162

what is median canaliform dystrophy?

Back 162

inverted fir tree (idiopathic or inherited)