Nail Pathology Lecture 1b PDF

BSc Podiatry (Hons) Program – Year 1 Pathology NAIL PATHOLOGY Sophie Hartfield, Lecturer in Podiatry Learning Objectives Outline terminology related to the nail unit Understand the presentation, causes and management of a range of common nail pathologies including: - Ony...

BSc Podiatry (Hons) Program – Year 1 Pathology NAIL PATHOLOGY Sophie Hartfield, Lecturer in Podiatry Learning Objectives Outline terminology related to the nail unit Understand the presentation, causes and management of a range of common nail pathologies including: - Onychauxis - Subungual Exostosis - Onychogryphosis - Beau’s Lines - Involution - Koilonychia - Onychocryptosis - Clubbing - Onychomycosis - Subungual Haematoma 2  Eponychium Dorsal nail plate Dorsal nail matrix Proximal nail fold Intermediate nail plate Ventral nail plate 5 6 3 7 ROOT 4 2 1 10 9 11 Hyponychium 8 Nail bed Ventral nail matrix Distal extent of Phalanx lunula 3 CAUSES OF NAIL DISEASE & PATHOLOGY CONGENITA ACQUIRED L Present from birth Systemic Traum Infectio Change/Diseas a n e Dermatologic Vascula Tumour al Change r s 4 TRAUMA What could be some causes of a traumatic nail pathology? Typically, trauma is either ACUTE or CHRONIC Acute: Referring to an injury generally, and typically occurring with a singular incident such as stubbing of the toe or someone stepping on the toe, or tripping over something etc. Chronic: Referring to an injury that occurs over a longer period of time, usually the result of frequent incidence of trauma. Could refer to inappropriate cutting of nails, lack of care (no cutting of nails), poor footwear choices which do not fit appropriately, secondary to anatomical changes 5 ONYCHAUXIS Referring to a thickened toenail Podiatry abbreviation – O/X Example: RF 1st O/X nail 6 ONYCHAUXIS SIGNS: Discoloration of the nail plate (typically brown/yellow) May show some evidence of partial detachment from the nail base May show subungual breakdown or ulceration beneath the nail plate due to pressure Abnormal thickening of the nail plate/hypertrophy Typically, thickness is increased distally Commonly involving the hallux, but also occurs on lesser digits Transverse ridges may be present (signs of Onychorrhexis) 7  Onychauxis pathogenesis NORMAL NAIL ONYCHAUXIC NAIL Cells within the nail matrix are The nail plate and the proximal nail directed distally and diagonally  fold become disorganised nail grows distally and not The proximal nail fold is shortened vertically and therefore the upper root matrix no longer has the strength to act The proximal nail fold is anchored against the forces occurring from firmly to the base and held at an the lower root matrix angle of 10-15º from the ventral root matrix via a wedge of The angle between the matrixes connective tissue and the upper increases  nail grows thicker and root matrix vertically Sample Footer Text 8  DIAGNOSIS Performed by observation of the signs and symptoms discussed Thorough and accurate history taking will also assist causation and diagnosis TREATMENT ONYCHAUXIS Nail should be reduced with nail nippers where possible initially. Subsequently thickness requires reduction with use of a nail drill and appropriate burr or manual file Removal of any debris or callus around the sulci Nail Surgery if warranted but typically not required 9  ADVICE Consider history of concern Protection (padding or cushioning) Footwear advice Self care techniques such as filing ONYCHAUXIS PROGNOSIS Condition will recur but condition can be managed Surgical intervention is the only way to prevent recurrence however this is typically not necessary 10 ONYCHAUXIS Referring to a thickened toenail which shows gross deformity and grows distally Podiatry abbreviation – O/G Example: RF 1st – 5th O/G nails SIGNS: Nail plate is hypertrophied as with an onychauxic nail Gross deformity is noted with curvature mimicking the shape of a “Ram’s Horn” Irregular opaque surface noted 11 ONYCHOGRYPHOSIS More features: Ridged nail plate Enlarged sulci Discolouration of nail Irregular opaque surface Gross deformity typically with lateral curvature into “Ram’s Horn” shape Often seen in elderly and infirm 12  SYMPTOMS May be uncomfortable especially if curving into ONYCHOGRYPHOSIS or affecting other digits Usually primary complaint is appearance, difficulty managing nail care and accommodation in footwear AETIOLOGY Trauma Peripheral Vascular Disease (PVD) Fungal infection of the nail plate Eczema, psoriasis Poor management of nails 13  Onychogryphosis pathogenesis Begins with uneven damage to the nail matrix  Uneven production of new cells  Influences direction of the nail growth  May increase the amount of nail keratin produced from the nail bed Sample Footer Text 14  TREATMENT Nail should be reduced with nail nippers initially, and any thickness present may require reduction ONYCHOGRYPHOSIS with use of a nail drill or manual file Removal of any debris or callus around the sulci Nail Surgery if warranted but as with O/X nails, typically not required PROGNOSIS Nail Surgery is an option to improve prognosis but again not necessary in most cases Condition will recur if left unattended to, however can certainly be managed with advice and podiatric care 15 ONYCHOLYSIS Referring to detachment of the nail plate from the nail bed Podiatry abbreviation – O/lysis or written in full as onycholysis SIGNS: Detachment of the nail Often attachment is distal to proximal, and presence of a half moon shape may be noted Can also detach from lateral borders White appearance occurs due to air within the subungual space 16 ONYCHOLYSIS More features: Debris often gathers beneath the lifted nail Moisture may also accumulate Linked to above, yellow/brown discolouration may be noted especially if fungal infection is present May or may not be uncomfortable Trauma and fungal infection are likely to be present or occur Possible systemic cause, secondary to psoriasis, reaction to chemical agent 17  PATHOLOGY Hard keratagenous material gathers from the exposed nail bed Increased pressure on the nail bed can cause inflammation and occasionally infection ONYCHOLYSIS TREATMENT Trim nail back in stages to proximal attachment, removing all detached nail Treat any fungal involvement and moisture concerns If an allergic response, advise removal of allergen from current and future use Referral to GP should be conducted if there is concern regarding any systemic involvement 18 ONYCHOMADESIS Referring to detachment of the nail plate from the nail bed BUT detachment is from the proximal aspect of the nail rather than the distal aspect as seen within onycholysis SIGNS: Detachment of the nail Often attachment is distal to proximal, and presence of a half moon shape may be noted Can also detach from lateral borders White appearance occurs due to air within the subungual space 19 SUBUNGUAL HAEMATOMA Referring to bleeding beneath the nail plate following an episode of trauma SIGNS/SYMPTOMS: Initially will be red in appearance from diffused blood Blood turns black/purple when coagulation occurs, and blood oxidizes Localised inflammation may be apparent around the traumatised Pain may be present due to built up pressure beneath the nail plate 20 SUBUNGUAL HAEMATOMA AETIOLOGY Usually caused by sudden trauma May be related to:  Sport related trauma e.g. football or marathon running  Systemic disease e.g. haemophilia  Minor trauma typically produces splinter hemorrhages (fine linear bruising along longitudinal dermal ridges of the nail plate) 21 SUBUNGUAL HAEMATOMA PATHOLOGY Severe trauma may hemorrhage the skin in addition to the nail and will involve more dermal ridges If a major trauma has occurred, the whole nail plate may be lost Systemic involvement – nail capillaries may rupture spontaneously, or this may be due to increased permeability of blood vessel walls 22 SUBUNGUAL HAEMATOMA DIAGNOSIS Observation of signs and symptoms, and thorough history gathering How did it occur? Did you notice the different discolouration after doing a specific activity? Could it be related to trauma or is it something systemic? If unusual presentation and history, it may be suspicious. Referral to GP may be required for consideration of melanoma. 23  SUBUNGUAL HAEMATOMA TREATMENT Treatment may or may not be required depending upon the state of the nail, symptoms and patient wishes PROGNOSIS If trauma was cause and is addressed, then treatment may solely involve awaiting nail regrowth. Subungual haematomas typically take about 8-12 months to grow through Lesser digit nails will often grow out more quickly 6-8 months approx. 24 INVOLUTION Referring to increased transverse curvature of the nail plate May be unilateral (affecting one side of the nail) or bilateral (affecting both sides of the nail) Curvature may pinch into the skin and be a precursor to onychocyptosis 25  TREATMENT Remove pressure from the sulci by resecting or trimming away the offending portion of nail Clear sulci of debris and smooth any rough edges Consider Nail Surgery  Partial Nail Avulsion or Total Nail Avulsion (PNA or TNA) with phenolisation of the nail matrix INVOLUTION ADVICE Ensure appropriate footwear is worn Hygiene and self care can be discussed Routine treatment of the nail as required Nail surgery is the most effective long-term solution if the patient is a suitable candidate 26 ONYCHOCRYPTOSIS Referring to an ingrown nail that has impacted the skin. An embedded spicule is typically present Podiatry abbreviation – O/C Example: LF 1st O/C present with hypergranulation tissue noted 27 ONYCHOCRYPTOSIS FEATURES: Spicule of nail or serrated edge has pierced the epidermal portion of the sulci Signs of inflammation will be present Toe may present with:  Oedema (swelling)  Inflammation  Bleeding/discharge  Unpleasant odour  Erythema (redness)  Heat  May be severely painful 28  ONYCHOCRYPTOSIS FURTHER CRITICAL SIGNS HYPERGRANULATION TISSUE may be present  Soft tissue mass which is notoriously prone to bleeding due to its vascular features  Tissue is fragile and red in colour  Can extend across the nail plate  Nail plate may be detached Whole toe may be inflammed Paronychia is also noted within the bottom image – referring to inflammation of the skin surrounding the nail 29  ONYCHOCRYPTOSIS AETIOLOGY Poor nail cutting technique “Picking of nails and skin” or Dermatillomania Trauma Involution of a more flexible nail Hyperhidrosis and maceration Long term effect of ill-fitting footwear 30  ONYCHOCRYPTOSIS Penetration of the sulcus by nail plate Bacterial contamination Inflammation and possible infection Nail spike prevents closure of wound Formation of hypergranulation tissue 31 ONYCHOCRYPTOSIS 32  ONYCHOCRYPTOSIS CONSERVATIVE MANAGEMENT APPROACH Removal of nail spicule from sulci with or without use of local anaesthetic Irrigation of area with sterile saline and an appropriate sterile dressing applied SURGICAL MANAGEMENT APPROACH Nail Surgery involving a Partial or Total Nail Avulsion with Phenolisation of the nail matrix (PNA or TNA) can offer a more permanent cure Should phenolisation fail, an extended scope podiatrist may be able to perform a skin surgery matrixectomy 33  ONYCHOCRYPTOSIS PROGNOSIS Dependent upon several factors:  What is the underlying cause?  Can this be prevented long-term?  Does the patient require routine care to manage the concern?  How much does the condition affect their daily activities?  Is there a history of infection and antibiotic requirement due to the presenting complaint?  How painful is it for the patient?  What is the patient’s health status and ability to self care?  Is the patient a suitable candidate for nail surgery? 34  ONYCHOMYCOSIS Referring to a fungal infection of the nail plate Podiatry abbreviation – O/M Example: LF superficial O/M noted to 2-5th nails and dystrophic O/M at LF 1st Total Superficial Distal Medial and Proximal Dystrophic O/M Lateral O/M White O/M White O/M 35  ONYCHOMYCOSIS FUNGAL NAIL Fungi are organisms which produce spores and are nourished by dead and decomposing matter Highly prevalent within the general population and very easily spread Different fungal organisms may be responsible for onychomycosis Most fungal infections are superficial (most common), however subcutaneous (more serious) and systemic (most serious) infections can also occur 36  ONYCHOMYCOSIS DERMATOPHYTES Dermatophytes are the leading cause of fungal nail infections (90%) Other 10% may involve non-dermatophytes such as yeasts or moulds Dermatophytes are a fungi requiring keratin for growth Approx 40 different species Can infect hair, skin, nails – any keratinous area Common organisms responsible for onychomycosis include… Trichophyton rubrum (~85%) Trichophyton mentagrophytes (~12%) 37  ONYCHOMYCOSIS PATHOLOGY Fungal organisms are typically keratinophilic and produce the enzyme keratinase which breaks down keratin, therefore able to affect a healthy nail plate DIAGNOSIS Observation of clinical features Specimens of nail can be sent to pathology laboratory for confirmation using microscopy and culture processes OR some accessibility to in clinic testing kits Reliability of these tests is often debatable Clippings of nail/nail dust/soft subungual debris scrapings may also be used for analysis 38  ONYCHOMYCOSIS TREATMENT Treatment options may involve:  Topical treatment (nail lacquer, dehydration of nail plate, natural antifungal ointments/preparations)  Systemic treatment (prescribed medication typically taken for 3-6 months and regularly reviewed such as oral terbinafine)  Destructive treatment (removal of the keratinous portion affected i.e. nail resection or nail surgery if warranted)  Some clinicians may opt for several combined strategies 39 SUBUINGUAL EXOSTOSIS Referring to an outgrowth of bone from the dorsal aspect of the distal phalanx SIGNS/SYMPTOMS: Pink or cherry red colour beneath nail plate which will blanche upon pressure being applied to the are Depending upon location, exostosis may cause an elevation of the nail plate from the nail base 40  Outgrowth of bone is beneath nail plate Commonly occurs in women especially at the hallux Typically, VERY PAINFUL SUBUNGUAL EXOSTOSIS Pain is noted to be constant and excruciating AETIOLOGY Idiopathic May be associated with trauma May be due to footwear, severe trauma, hyperextended hallux receiving excessive pressure in footwear 41  PATHOLOGY Irritation and elevation of the periosteum results from incident Outgrowth of bone ossifies Appears as a “mushroom” like formation SUBUNGUAL EXOSTOSIS consisting of primarily osteoblasts and osteocytes DIAGNOSIS Consider signs and symptoms Confirmation via x-ray imaging TREATMENT Surgical procedure to remove exostosis if causing concern = Exostectomy 42 DIFFERENTIAL DIAGNOSIS DDX ACRAL (DIGITAL) FIBROMYXOMA Always consider differential diagnosis Although a rare finding, it a distinctive soft tissue tumour associated with the toes, fingers and nail beds. This benign tumour is typically painless and slow growing. 43 NAIL CLUBBING Referring to enlargement of the distal portion of the digit which also enlarges and causes a bulbous appearance to the nail plate SIGNS/SYMPTOMS: No abnormality to the underlying phalanx Normally involves toes and fingers Hypertrophic changes of soft tissues surrounding the nail 44 NAIL CLUBBING AETIOLOGY Cardiovascular disease Smoking Malnutrition Endocrine disorders Aortic Aneurysm 45 KOILONYCHIA Referring to a spoon shaped contour to the nail plate SIGNS/SYMPTOMS: Nail plate becomes concave No changes to nail thickness occur All nails tend to be involved 46 KOILONYCHIA AETIOLOGY Iron-deficiency anaemia, especially in children Dermatological: e.g. psoriasis Occupational: e.g. oils, chemicals Infections: e.g. onychomycosis PATHOLOGY Spoon shape occurs when the distal part of the nail matrix is low compared to the proximal end In anaemic patients this may occur due to anoxia and atrophy of connective tissue 47 BEAU’S LINES Referring to horizontal ridges or dents in one or more nails SIGNS/SYMPTOMS: Transverse bands extend from one lateral edge of the nail plate to the other Appear at the Lunula and then progress distally with nail growth Typically, superficial but can cause separation of the nail at the level of Beau’s Lines 48 BEAU’S LINES AETIOLOGY If all nails are affected this typically intimates a systemic disease is present e.g. fever, post-natal, measles, chronic paronychia, eczema Sudden interruption of the growth pattern at the nail matrix Occurs roughly 1 month after the initiating stress that affected the growth e.g. measles, coronary thrombosis, severe mental stress 49 ONYCHORRHEXIS Refers to a brittleness of the nail plate typically with vertical ridges which form on the nail plate Not always a concern or indicative of any problem Often indicates microtrauma and aging May also be a result of thyroid concerns, anaemia and nutritional deficiency 50 NAIL PITTING Refers to small round depressions or notches which appear in the nails AETIOLOGY Common in conjunction with skin and autoimmune disorders such as psoriasis and eczema May be associated with connective tissue disorders such as Reiter’s syndrome and osteoarthritis Dermatitis may also cause this to occur Mineral deficiencies may also contribute 51  CHROMONYCHIA Refers to change or abnormality of the colour and pigmentation of the nail plate Recommended reading: https://ijdvl.com/nail-dyschromias/ Yellow Nail Leuconychia Green nail Melanonychi a 52  Further pathologies to ponder… Onychophosis Onychomadesis Durlacher’s Corn Pachyonychia Subungual Heloma Durum Onychotillomania Paronychia Onychopapilloma Onychoschizia/onychoschisis Sample Footer Text 53  POST LECTURE CONSOLIDATION Post-lecture consolidation: 1. Review the lecture notes and supporting research article 2. Attempt the MCQ quiz at the end of this learning unit and test your knowledge! Sample Footer Text 54