Nail Whispers Revealing Dermatological and Systemic Secrets: An Analysis of Nail Disorders Associated With Diverse Dermatological and Systemic Conditions

Abstract

Background and objective Nail disorders encompass a wide spectrum of conditions, spanning congenital, developmental, infectious, neoplastic, degenerative, dermatological, and systemic diseases. A comprehensive exploration of their clinical manifestations, incidence, and associations is crucial for precise diagnosis and effective management. Methods This observational cross-sectional study conducted at B.J. Medical College and Civil Hospital, Ahmedabad involved 300 consecutive patients with nail changes from July 2017 to June 2019 reporting diverse dermatological and systemic conditions. The inclusion criteria involved patients of both genders and all age groups displaying nail changes associated with dermatological and systemic diseases. Data collection entailed a comprehensive clinical history, systemic and dermatological examinations, nail assessment using Dermoscope (DermLite 3, 10x), and supplementary tests. Analyses were performed on Microsoft Excel 2007 software. The study was approved by the Institute Ethics Committee. Results Among the 300 cases, females had a higher prevalence of nail involvement (57%), with a female-to-male ratio of 1.3:1. The most affected age group was 21-40 years, with 6-10 nails typically affected. Notably, housewives showed a higher prevalence. The most frequent nail condition was onychomycosis (24.33%) followed by psoriatic nail changes (20%). Less frequent nail changes involved eczema (5.7%), paronychia (5%), drug-induced (4.3%), lichen planus (3.7%), trauma-induced (3%), twenty nail dystrophy (2.33%), Darier's disease (2%), pemphigus vulgaris (2%), alopecia areata (1.67%), median Heller dystrophy (1.33%), atopic dermatitis (1%), epidermolysis bullosa (1%), racquet nail (1%), leprosy (1%), pityriasis rubra pilaris (0.67%), vitiligo (0.67%), secondary syphilis (0.67%), pachyonychia congenita (0.67%), as well as a case each of total leukonychia, subungual warts, Koenen tumor, and periungual fibroma(0.33%). Systemic autoimmune connective tissue disorders (CTD) accounted for 9%; the most common nail finding observed was nail fold erythema (48.1%) followed by nail fold telangiectasis (44.4%). In systemic sclerosis (SS), the most common finding was nail fold telangiectasia, and in systemic lupus erythematosus (SLE), the most common was nail fold erythema. Scleroderma capillary pattern on nail fold capillaroscopy was found in seven patients with SS, two patients with dermatomyositis, and only one patient with SLE. Nail changes observed in systemic diseases include onychomycosis in diabetes mellitus and chronic renal failure patients, splinter hemorrhages in ischemic heart disease and hypertension, longitudinal melanonychia in HIV, and koilonychia and platynychia in iron deficiency anemia. Other systemic diseases, such as Addison's disease and renal failure, also exhibited various nail changes. Conclusions Beyond their cosmetic importance, nails hold a vital pathologic role. Proficiency in nail terminology and classification is key for skillful evaluation. Understanding normal and abnormal nail variants, along with their disease associations, benefits diagnosis and tailored management. Nails, often overlooked but accessible, serve as a window into patients' general health and should be an integral part of thorough examinations. This study highlights an intricate clinical panorama of nail disorders, highlighting their significant role in both dermatological and systemic contexts.

Keywords: connective tissues disease; dermoscopy; epidemiology; nail diseases; nail psoriasis; onychomycosis; trachyonychia.

Figure 1. Morphological patterns of onychomycosis

A1: superficial white onychomycosis (SWO); A2: total dystrophic onychomycosis (TDO); A3: proximal subungual onychomycosis (PSO); A4: distal lateral subungual onychomycosis (DLSO)

Figure 2. Nail plate discoloration in onychomycosis

Figure 3. Nail changes in psoriasis

C1: pitting; C2: Beau's lines; C3: subungual hyperkeratosis; C4: onycholysis

Figure 4. Nail changes in lichen planus

D1: pterygium in toe nail; D2: onychodystrophy with lichen planus skin lesions; D3 and D4: Beau's lines and longitudinal ridging; D5: pterygium under dermoscopy

Figure 5. Trachyonychia (twenty nail dystrophy) seen in a patient with alopecia areata

Figure 6. Nail changes in pemphigus vulgaris

E1: onychomadesis; E2: dermoscopic image of onychomadesis; E3: paronychia, onychodystrophy

Figure 7. Various nail findings in systemic diseases

F1: onychomycosis in a diabetic patient; F2: splinter hemorrhages in the dermoscopic image of the fingernail in a patient with hypertension and ischemic heart disease; F3: koilonychia in a patient with anemia

Figure 8. Nail changes in Addison's disease

G1: nail plate discoloration and facial hyperpigmentation in a patient with Addison's disease; G2, G3: dermoscopic images of the same patient showing nail plate discoloration

Figure 9. Drug-induced nail changes

H1: doxorubicin-induced chromonychia; H2: carbamazepine-induced anonychia; H3: carboplatin-induced onychodystrophy; H4: cisplatin-induced Beau's lines; H5: zidovudine-induced melanonychia; H6: gemcitabine-induced onychomadesis

Figure 10. Various nail changes observed in our study - 1

I1: onycholysis, subungual hyperkeratosis, and thickening of the nail plate in pityriasis rubra pilaris; I2: loss of the nail plate in epidermolysis bullosa; I3: onychodystrophy in pachyonychia congenita

Figure 11. Various nail changes observed in our study - 2

J1: Mee's lines were seen in a chronic renal failure patient; J2: total idiopathic leukonychia; J3: ingrown toenail; J4: hereditary clubbing

Figure 12. Various nail changes observed in our study - 3

K1: onychogryphosis in a post-burn patient; K2: pincer nail due to finger trauma; K3: periungual Wart; K4: median Heller dystrophy; K5: racquet nail; K6: Koenen tumor seen in tuberous sclerosis

Figure 13. Various nail changes observed in our study - 4

L1: 'V'-shaped nicking in Darier's disease; L2: half-and-half nail seen in chronic renal failure; L3: onychoschizia; L4: triangular lunula seen in eczema