At a Glance - Nail clubbing versus pincer nails

Contributed by Dr Jean Watkins, a sessional GP in Hampshire.

Nail Clubbing


Clinical features

  • Most often associated with disease, eg lung cancer, TB, abscess, cyanotic congenital heart disease, chronic hypoxia, bacterial endocarditis, Crohn's, ulcerative colitis, malabsorption, cirrhosis, hyperthyroidism.
  • Familial.
  • Affects finger and toe nails.
  • Gradual onset of loss of the normal angle between the nail bed and the nail fold.
  • Nail fold and nail show increased convexity.
  • Thickening of the soft tissue alone or all of the terminal phalanges of the digit so it appears like a drumstick.
  • Skin and nail appear shiny.
  • Painless.

Management

  • Seek a cause by taking a history and examining the patient.
  • Reversal of the changes may occur if the underlying condition is treated.

Pincer (involuted nails)

Clinical features

  • May be of congenital origin and present at birth.
  • Occasionally family history of the condition.
  • May develop later in life due to tightly fitting footwear with pressure on the nail plate.
  • Malnutrition may be a risk factor.
  • Most commonly affects the big toe.
  • Inward curving of the nail toward the nail bed at the medial and/or the lateral margins.
  • Causes reduction in circulation to the nail and matrix.
  • May cut into the sulcus leading to painful ulceration and the risk of infection.

Management

  • Careful manicure of nails and reduction of thickening of the incurved edges is sufficient in minor cases.
  • Footwear advice.
  • A nail brace to lift the nail and reduce pressure may help to ease minor problems.
  • In more severe cases, partial nail avulsion may be required.
  • In very severe cases, total avulsion of the nail and destruction of the matrix may be necessary.
  • Newer approaches aim to restore the shape of the nail with dermal grafts.

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