INTRODUCTION

Nails are a reflection of both internal and external disease. Functions of nail are to assist in picking up small objects, to protect the distal digit, to improve fine touch sensation, and to enhance esthetic appearance of hands.

Nail disorders include those abnormalities that affect any portion of nail unit. The nail unit includes nail plate; nail matrix; bed; proximal, lateral, and distal nail fold; and hyponychium. These structures may be affected by heredity, skin disorders, infections, systemic disease, ageing, internal and external medications, physical and environmental agents, trauma, and tumors both benign and malignant.

Nail disorders comprise 10% of all dermatological conditions. The accurate recognition and description of nail findings is the crucial first step in diagnosing a nail disorder. The worldwide incidence of nail disorders is increasing and it continues to spread and persist.

AIMS AND OBJECTIVES

To study the clinical spectrum of nail disorders including: congenital, developmental, infectious, neoplastic, degenerative, dermatological, and systemic diseases affecting the nail unit.

MATERIALS AND METHODS

  • A total of 100 consecutive cases of nail disorders reporting to dermatology outpatient department in Rohilkhand Medical College & Hospital, Bareilly, Uttar Pradesh, India were examined.

  • Complete dermatological, systemic examination, hematological examinations, Gram staining, scraping for fungus, nail clipping for potassium hydroxide mount, fungal culture, and biopsy from nail bed were undertaken in doubtful cases.

OBSERVATION AND RESULTS

  • A total of 100 cases with nail changes were subjected to study.

  • Age group of cases varied from 4 to 74 years, mean age being 36.05 years.

  • Duration of nail disorders ranged from 5 to 35 years, mean duration being 2.84 years.

Systemic Diseases

From the chart, among the 29 cases, the following were observed:

  • Nail change in diabetes mellitus: Onychomycosis — 8 cases, onychogryphosis — 1 case, onychomadesis — 1 case.

  • Chronic renal failure on dialysis: Onychomycosis — 3 cases, half and half nail — 2 cases

  • Ischemic heart disease and hypertension: Onychomycosis — 3 cases, onychogryphosis — 1 case

  • Human immunodeficiency virus (on highly active antiretroviral therapy): Nail discoloration — 2 cases

  • Iron deficiency anemia: Koilonychia — 3 cases

  • Systemic sclerosis: Clubbing with resorption of terminal phalanges — 2 cases

  • Chronic obstructive pulmonary disease and Koch's: Clubbing — 3 cases.

DISCUSSION

Among 100 cases observed, male to female ratio was 2:1 (Graph 1). The most common age group involved was 31 to 40 years (30%) followed by 21 to 30 years (19%). Nageshwaramma et al1 did a study and observed most common age group involved was 21 to 40 years (40%). Among 100 cases (Table 1, Figs 1 to 13 and Graph 2), the most common change was onychomycosis — 28%. Distal and lateral subungual onychomycosis (DLSO) was observed to be most common morphological pattern — 59.26%. It was comparable to studies done by Veer et al2 (50%) and Grover3 (85%) (Table 2). Nail psoriasis accounts for 13% of cases. The most common nail finding in psoriasis was pits (46.5%) followed by subungual hyperkeratosis and onycholysis. Puri and Kaur4 did a study and found pitting as a common manifestation in psoriasis (70%), followed by subungual hyperkeratosis and onycholysis. Pitting was seen in 10% cases. Cause was idiopathic. Trachyonychia was seen in 5% of cases. Cause was idiopathic in 40% cases, alopecia areata in 40% cases, and lichen planus in 20% cases.

Table 1

Spectrum of nail disorders observed

DiseaseNumber of cases
Onychomycosis28
Nail psoriasis13
Pitting10
Paronychia9
Trachyonychia5
Onycholysis4
Clubbing3
Koilonychia3
Ingrow toe nail3
Pterygium3
Onychogryphosis2
Subungual wart2
Half and half nail2
Anonychia2
Longitudinal groove2
Clubbing with resorption of terminal phalanges2
Onychomadesis1
Nail discoloration1
Melanonychia1
Pachyonychia congenita1
Beau's lines1
Racket nail1
Transverse groove1
Total100
Graph 1

Sex distribution

ijaims-2-125-g001.tif
Fig. 1

Onychomyosis

ijaims-2-125-g002.tif
Fig. 2

Nail psoriasis

ijaims-2-125-g003.tif
Fig. 3

Trachyonychia

ijaims-2-125-g004.tif
Fig. 4

Clubbing

ijaims-2-125-g005.tif
Fig. 5

Pterygium

ijaims-2-125-g006.tif
Fig. 6

Subungual wart

ijaims-2-125-g007.tif
Fig. 7

Transverse groove

ijaims-2-125-g008.tif
Fig. 8

Racket nail

ijaims-2-125-g009.tif
Fig. 9

Melanonychia

ijaims-2-125-g010.tif
Fig. 10

Nail discoloration

ijaims-2-125-g011.tif
Figs 11A and B

(A) Ingrow toe nail and paronychia; (B) Koilonychia

ijaims-2-125-g012.tif
Figs 12A and B

(A) Onycholysis; and (B) Half and half nail

ijaims-2-125-g013.tif
Fig. 13

Pachyonychia congenita

ijaims-2-125-g014.tif

Gordon et al5 did a study and observed most common cause of trachyonychia was idiopathic and other being lichen planus and alopecia areata.

CONCLUSION

No cutaneous examination is complete without a careful evaluation of the nails. Nails remain an understudied and yet quite accessible structure that lends itself for examination and evaluation. In our study, male preponderance was seen. Onychomycosis was the most common finding. The DLSO was most common morphological pattern observed, followed by nail psoriasis, pitting, paronychia, trachyonychia, and other disorders (Tables 3 and 4).

Graph 2

Spectrum of nail disorders observed

ijaims-2-125-g015.tif
Table 2

Morphological pattern of onychomycosis

Morphological patternTotal% (this study)Veer et al2Grover3
DLSO1659.265082
PSO412.9620.46
SWO39.2622
TD27.4146
PSO with paronychia27.410.24
Subungual hyperkeratosis13.7
Total28100
DLSO: Distal and lateral subungual onychomycosis; PSO: Proximal subungual onychomycosis; SWO: Superficial white onychomycosis; TD: Total dystrophy
Table 3

Nail changes in psoriasis

Nail changesFingernailToe nailBothTotalPercentage
Pitting312646.15
Pitting and transverse groove117.6
Pitting, onycholysis, and subungual hyperkeratosis12323
Total nail dystrophy117.6
Transverse groove117.6
Yellow discoloration and pitting117.6
13100
Table 4

Causes of trachyonychia

Associated diseaseTotalPercentage
Alopecia areata240
Lichen planus120
Idiopathic240
Total5100
Conflicts of interest

Source of support: Nil

Conflict of interest: None