In this month’s column, Dr. Stern encounters patients dealing with psoriasis; red, spotted lunula; lichen planus; myxoid cyst; and chemotherapy affecting the nails.
Onycholysis (nail separation) secondary to nail psoriasis.
Pitting of nail secondary to nail psoriasis.
Patient is a 38-year-old female with a history of abnormal fingernails for almost two years. She was told she had a fungal infection. She also has a history of flaking at the scalp.
Assessment: Onycholysis and nail plate pitting secondary to psoriasis. Psoriasis is an inflammatory, auto-immune condition that can affect the skin as well as the nails and joints. Onycholysis is when there is inflammation of the nail bed causing the nail plate to separate from the underlying bed. The normal white tip of the nail appears to be tracking toward the cuticle in this condition. The white/yellow opacity is air that is under the nail. Additionally, once there is a space under the nail, it becomes an ideal moist environment for organisms such as yeast to reside. Pits in the nail are pinpoint depressions in the nail plate that are due to psoriasis of the nail matrix. Most nail psoriasis patients develop nail lesions after they have skin involvement. Less than 10% of nail psoriasis patients have only nail involvement.
Hemorrhagic onycholysis secondary to side effect from chemotherapy. Note the copper/brown patches that are secondary to bleeding at the nail bed.
Patient is a 62-year-old female with a history of breast cancer who was recently treated with chemotherapy. The nails have been separating and have been quite painful.
Assessment: Hemorrhagic onycholysis secondary to chemotherapy side effect. Many of the newer chemotherapy drugs have nail side effects. It is important for cancer patients or any person who is immunosuppressed to be especially cautious about infection risks in a nail salon. Any client with separated nails should seek treatment by a dermatologist and avoid nail cosmetics until the problem is completely resolved.
Red, spotted lunula, in this case secondary to psoriasis. Other causes include alopecia and lichen planus.
The patient is a 54-year-old male who presented with a one-year history of what he described as “peculiar red spots” in the half moon of the nail as well as separation.
Assessment: Red, spotted lunula and mild onycholysis (separation) secondary to psoriasis. Red, spotted lunula are not specific to psoriasis as this interesting clinical finding can also be seen associated with alopecia (hair loss) and lichen planus.
Lichen planus of the nail.
The patient is a 32-year-old male who presented with a four-year history of abnormal fingernails and toenails. He was very embarrassed about the appearance of his nails. On examination, the nails appeared to have longitudinal ridging and the nail plates were significantly thinned.
Assessment: Lichen planus of the nail. Lichen planus is an inflammatory disorder that can involve the skin, mucous membranes, nails, and/or scalp. It can be very challenging to treat and in aggressive cases can lead to irreversible scarring of the nail.
Myxoid cyst resulting in a longitudinal groove of the nail.
Myxoid cyst showing gelatinous content typical of this type of cyst.
The patient is a 43-year-old female who presented with a nine-month history of a painless abnormality at the left index fingernail. She reports a history of arthritis.
Assessment: Myxoid cyst. Also known as digital mucous cyst, a myxoid cyst is a firm, smooth, often bluish, fluid-filled bump on the skin. These cysts frequently appear on the fingers near the nail and are more common in people who have arthritis. When the cyst comes into contact with the nail matrix, a depression or groove can appear in the nail, thus distorting the appearance of the nail.
Dr. Dana Stern
Dermatologists treat skin, hair, and nails. I am a board-certified dermatologist and I specialize in the treatment of nail disorders including nail infections, inflammatory diseases of the nail, cosmetic issues related to the nail, cancers of the nail, and sports-related nail injuries.
Most of my consultations are from other dermatologists, physicians, or patients who have read about me. I also see patients referred from nail salons. I love the fact that my day is not predictable. I am constantly meeting new patients from all walks of life and I never know what interesting nail case awaits me when I enter the examination room.
You can contact Dr. Stern with your questions via Facebook (www.facebook.com/danasternmd) or Twitter (@DrDanaStern). Visit her website at www.drdanastern.com.
Read previous “day in the life” articles by Dr. Stern at www.nailsmag.com/danastern.