Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients

Observing the Nail Shape and Surface

Clubbed Fingernails

Clubbing involves a softening of the nail bed with the loss of normal Lovibond angle between the nail bed and the fold, an increase in the nail fold convexity, and a thickening of the end of the finger so it resembles a drumstick.

To determine whether nails are clubbed, have the patient place both forefinger nails together and look between them. If you can see a small diamond space between them (Schamroth's window) then the nails are not clubbed (Schamroth's sign) (Figure 2).

Figure 2. Schamroth's sign.

Causes of clubbing (not exhaustive) include the following (Figure 3):

• Pulmonary and cardiovascular causes (80%)
  
  
• • Lung cancer, pulmonic abscess, interstitial pulmonary fibrosis, sarcoidosis, beryllium poisoning, pulmonary arteriovenous fistula, subacute bacterial endocarditis, infected arterial grafts, aortic aneurysm
    
    
• Gastrointestinal causes (about 5%)
  
  
• • Inflammatory bowel disease, sprue, neoplasms (esophagus, liver, bowel)
    
    
• Hyperthyroidism (about 1%)
  
  

Note: Chronic obstructive pulmonary disease does not cause clubbing.

Figure 3. Example of clubbed fingernails.

Koilonychia

Koilonychia are spoon-shaped concave nails (Figures 4A, 4B). This occurs normally in children and usually resolves with aging. To determine whether a nail is spooned, perform the water drop test. Place a drop of water on the nail. If the drop does not slide off, then the nail is flattened from early spooning. An experienced clinician can look at the nail and perform a "mental" water drop test. Causes include the following:

• Iron deficiency;
  
  
• Diabetes mellitus;
  
  
• Protein deficiency, especially in sulfur-containing amino acids (cysteine or methionine);
  
  
• Exposure to petroleum-based solvents;
  
  
• Systemic lupus erythematosus; and
  
  
• Raynaud's disease.

Figure 4A. Spooned nail.

Figure 4B. Spooned nail.

In 1846, Joseph Honoré Simon Beau described transverse lines in the substance of the nail as signs of previous acute illness. The lines look as if a little furrow had been plowed across the nail. Illnesses producing Beau's lines include the following:

• Severe infection;
  
  
• Myocardial infarction;
  
  
• Hypotension, shock;
  
  
• Hypocalcemia; and
  
  
• Surgery.

Intermittent doses of immunosuppressive therapy or chemotherapy can also produce Beau's lines. Severe zinc deficiency has also been proposed as a cause of Beau's lines.

By noting its location on the nail, the approximate date of the illness associated with it can be determined (Figures 5A, 5B). Moreover, the depth of the line provides a clue to the severity of the illness.

Figure 5A. The location of Beau's lines half way up the nail suggests illness 3 months ago.

Figure 5B. Two Beau's lines suggest illnesses about 2 months apart.

Thin Brittle Nails

Thin, brittle nails can indicate the following (Figure 6):

• Metabolic bone disease (nail thinness is correlated with osteopenia);
  
  
• Thyroid disorder;
  
  
• Systemic amyloidosis (indicated by yellow waxy flaking); and
  
  
• Severe malnutrition.

Figure 6. Note the thin nails in this woman with severe osteopenia.

Onychorrhexis is the presence of longitudinal striations or ridges (Figure 7). It can simply be a sign of advanced age but it can also occur with the following:

• Rheumatoid arthritis;
  
  
• Peripheral vascular disease;
  
  
• Lichen planus; and
  
  
• Darier's disease (striations are red/white).

Central ridges can be caused by:

• Iron deficiency;
  
  
• Folic acid deficiency; and
  
  
• Protein deficiency.

Figure 7. Example of a central nail ridge.

Central Nail Canal (Median Nail Dystrophy)

When a central nail canal is present, the cuticle is usually normal (Figure 8A). Central nail canal is associated with:

• Severe arterial disease ("Heller's fir tree deformity" -- a central canal with a fir tree appearance -- may occur with peripheral artery disease (Figure 8B);
  
  
• Severe malnutrition; and
  
  
• Repetitive trauma.

Figure 8A. Example of central nail canal.

Figure 8B. Central nail canal with Heller's fir tree deformity.

Nail Pitting

Nail pitting -- small punctate depressions -- are caused by nail matrix inflammation, which can be the result of:

• Psoriasis (random appearance of pits) (Figure 9);
  
  
• Alopecia areata (geometric rippled grid) (Figure 10);
  
  
• Eczema; and
  
  
• Lichen planus.

Figure 9. Indication of psoriasis.

Figure 10. Indication of alopecia areata.

Nail Beading

With nail beading, the beads seem to drip down the nail like wax (Figure 11). It is associated with endocrine conditions, including the following:

• Diabetes mellitus;
  
  
• Thyroid disorders;
  
  
• Addison's disease; and
  
  
• Vitamin B deficiency.

Figure 11. Nail beading.

Rough Nail Surface

When nails look sandpapered and dull, consider (Figure 12):

• Autoimmune disease;
  
  
• Psoriasis;
  
  
• Chemical exposure; and
  
  
• Lichen planus.

Figure 12. Example of a rough nail surface.

Nail Thickening

Slow nail growth produces thickness (Figure 13). In such cases, the following should be considered:

• Onychomycosis;
  
  
• Chronic eczema;
  
  
• Peripheral vascular disease;
  
  
• Yellow nail syndrome; and
  
  
• Psoriasis.

Figure 13. Example of a nail thickening.

Onycholysis

Onycholysis is distal separation of the nail plate from the underlying nail bed (Figure 14). It is associated with the following:

• Thyrotoxicosis;
  
  
• Psoriasis;
  
  
• Trauma;
  
  
• Contact dermatitis;
  
  
• Tetracycline;
  
  
• Eczema;
  
  
• Toxic exposures (solvents);
  
  
• Blistering from autoimmune disease; and
  
  
• Porphyria cutanea tarda (onycholysis and skin blistering from sun exposure).

Figure 14. Traumatic onycholysis (involving only 1 nail).

Severe Nail Curvature (Beaked Nails)

Curved or beaked nails are caused by resorption of distal digit (Figure 15). Consider the following:

• Hyperparathyroidism
  
  
• Renal failure
  
  
• Psoriasis
  
  
• Systemic sclerosis

Figure 15. Example of severe nail curvature.

Complete Nail Destruction

Complete local nail destruction can be caused by local mechanisms, including trauma and paronychia. Generalized conditions that might cause complete nail destruction include the following:

• Toxic epidermal necrolysis;
  
  
• Chemotherapy;
  
  
• Bullous diseases; and
  
  
• Vasculitis.