In her second column, Dr. Stern covers spoon-shaped nails, Mee’s lines, habit tic, and more.
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. I also perform surgery on the nail including biopsies and excisions. My initial interest in nails was like most things in life, somewhat random. Early in my training at Mount Sinai Hospital in New York City, the chairman of my department encouraged me to apply for a research grant to study nails. He suggested I study brittle nails because it was such a controversial topic in the medical literature. In 2007, our first study was published in The Journal of the American Academy of Dermatology. I have been passionate about nails ever since.
Most of my consults 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.
Patient is a 74-year-old female with a five-month history of abnormal appearance of the right thumbnail. There was no history of trauma and no pain.
Assessment: Koilonychia, also referred to as “spoon-shaped nails,” are concave in appearance so that a drop of water could balance on the surface of the nail plate without rolling off. Although there are many potential causes, the most common include iron deficiency anemia, trauma, psoriasis, and Raynaud’s. Often the cause is not completely clear but it is always important to check blood work to look for anemia.
Patient is a 41-year-old female with a history of a wart at the left thumbnail for more than three years. When she came to me for consultation she reported a history of several years of unsuccessful therapy including freezing the wart.
Assessment: This is a great example of a wart that has impinged on the growth of the nail causing the nail to grow abnormally (nail dystrophy). If you look at the skin that is just in front of the cuticle you can see a rough looking plaque and this is the part of the wart that is visible. However, the wart also continues to extend deep and this is why it was not responsive to simple freezing. I surgically removed the wart so it was no longer interfering with the growth of the nail.
The patient is a 32-year-old male who presented with a 10-year history of abnormal thumbnails. He was very embarrassed about the appearance of his nails and admitted to a habit of pushing the cuticles of the thumb nails back with his index fingers.
Assessment: Habit-tic deformity is an acquired habit-induced condition of the nails secondary to the repetitive habit of picking or pushing the cuticle of the thumbnail back. You can see a series of parallel, transverse depressions along the central access of the nail plate in a so-called “washboard” configuration. Additionally the lunula is often enlarged. There is always a ragged or absent cuticle and the patient may or may not be aware of the habit. Any repetitive trauma to the cuticle can ultimately result in the abnormal outgrowth of the nail because the cuticle directly overlies the nail matrix and the nail matrix is what becomes the actual nail. Therefore, overly aggressive cuticle removal or even pushing back of the cuticle can, when repetitive, affect the cosmetic appearance of the nail. I treated this patient by offering a solution for repair of the cuticle and we also discussed behavioral modification. He was very pleased with the outcome (see post-treatment photo).
The patient is a 19-year-old male who presented with an eight-month history of abnormal white lines on all 20 nails.
Assessment: Mee’s lines are a type of leukonychia (white nail). The white color follows the contour of the lunula (half moon). Arsenic poisoning is the classic cause of Mee’s lines, however there are also many other potential medical causes including certain vitamin deficiencies and infections. A complete medical work up and extensive blood work are imperative.
The patient is a 43-year-old female who presented with a nine-month history of something painless growing on her right great toenail.
Assessment: This horn-like projection is a benign tumor called an acquired digital fibrokeratoma. These tumors tend to occur on hands, feet, and nails. Treatment is surgical removal although they may recur. I surgically excised this tumor and so far we have been lucky and it has not grown back.
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