Nail Disease: Clinical Pearls from Phoebe Rich

  1. In a patient with chronic onycholysis with oozing that is unresponsive to therapy, consider Bowen’s disease of the nail bed.
  2. A thickened nail with white longitudinal and channels with splinter hemorrhages are likely to be an onychomatricoma.
  3. Brittle nails can be caused by or exacerbated by anemia and hypothyroidism.
  4. New onset pincer nails can be drug induced, the most common of which is beta blockers.
  5. A strong association of subungual glomus tumors and type 1 Neurofibromatosis has been identified.
  6. Longitudinal erythronychia (red band in the nail) is most commonly due to an onychopapilloma but other rare causes include SCC and amelanotic melanoma.

Nail Disease: Clinical Pearls

Nat Jellinek, MD

Clinical Pearls from Dr Jellinek discussing an in-depth range of nail topics…

  • Longitudinal melanonychia may represent a heterogeneous group of conditions, from primary melanocytic causes to fungal/bacterial infections, hemorrhage, and exogenous causes, among others.  The dermatologist’s job is to diagnose nail melanoma.
  • Too often early nail melanoma, presenting as longitudinal melanonychia, is observed rather than biopsied.  Clinically differentiating benign from malignant is difficult.  Biopsy and pathologic examination remains the gold standard for diagnosis.  Earlier biopsies diagnose earlier melanoma.
  • Digital myxoid cysts represent ganglions from the DIPJ.  Most treatments, one way or another, involve scarring the stalk that extends from the joint to the tissues around the nail.
  • Nail squamous cell carcinoma is usually associated with HPV-16.  It is difficult to clinically differentiate refractory-to-treatment ungual/periungual warts from carcinoma.  Only biopsy with depth can make this diagnosis reliably.
  • Midline nail dystrophies are often confusing, with habit tic deformity and median canaliform dystrophy occasionally demonstrating overlap features.  Careful examination can usually distinguish the two.