Causes of nail changes

Contributed by Dr Jean Watkins, a sessional GP in Hampshire

Leukonychia

Leukonychia presents as transverse white streaks or spots on the nail. The cause of these changes are unknown but they are thought to be related to trauma or enthusiastic manicuring of the nails and are not normally of any significance. Previously there has been the belief that leukonychia is caused by calcium deficiency. This is now thought to be untrue. The patient can be reassured that they should grow out in time.

Trauma

This patient claimed that the changes in his nail bed had followed a period of torture some 20 years earlier and since that time they had not improved. Apart from the appearance and constant reminder of his ordeal they were now symptomless.

In some cases of persistent leukonychia the whole of the nail may be white. This occurs in families where there is an inherited autosomal dominant gene.

Underlying disease

Nails are often an indicator of disease. In some cases of leukonychia, the proximal half of the nail is white and the distal half reddened or brown.

Such changes may suggest underlying disease such as renal failure, congestive heart failure or cirrhosis of the liver. The patient should be examined and investigated so that the appropriate management of the case can be started.

Tinea unguium

This patient presented with a well-defined white streak across the big toe nail. Trichophyton mentagrophytes was found. This species is known to produce a superficial, white discolouration of the nail. The condition may respond to topical tioconazole, ketoconazole, amorolfine or terbinafine. However, topical preparations are not very effective unless combined with a systemic antifungal agent such as terbinafine.

Yellow nail syndrome

In yellow nail syndrome the nails grow slowly, become thicker, markedly curved and develop a pale yellow or greenish yellow colour. It can affect all the nails.

The cause is unknown but it is often seen with lymphoedema, bronchiectasis or pleural effusions. Any treatment should be aimed at the underlying condition. However, once developed the changes are usually permanent. Vitamin E supplements can be helpful.

Darier's disease

Darier's disease is a rare inherited skin condition caused by an autosomal dominant gene. Specific nail changes occur, with V-shaped notches at the nail edge and white or reddish longitudinal stripes on the nails. A skin biopsy should confirm the diagnosis. Other symptoms are a rash of greasy, warty papules that occur mainly on the face, scalp, trunk, flexures and groin. Treatment involves emollients and antibiotics.

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