powerpoint presentation · © endeavour college of natural health 6 common nail signs sign...

HMCL312

www.endeavour.edu.au

Session 8

Nail signs

© Endeavour College of Natural Health www.endeavour.edu.au 2

SN08 Overview

Nutrient deficiency and disease associated Nail Diagnosis

Pre-Assessment Considerations:

o Working hypothesis of the pattern of disturbance

o Differential diagnoses

o Duty of care

o Medical ‘Red Flags’ - referral


Nail assessment

In the clinical setting, the nails provides a quick, easily accessible and non-

invasive means of assessment. In the context of Objective data, nails can

indicate overall health of the client and guide towards further questioning and

investigations. In general they give information about:

o Dietary intake

o Digestive absorption

o Blood flow

o Nutritive value of the blood


Common Causes of Nail Abnormalities

o Abnormalities in the colour,

shape, texture, size or thickness

of the nails are often the result of

either injury, infection, disease,

poisoning, nutritional deficiency

or genetic pre-disposition, and

can provide many clues as to

underlying systemic disease

long before other symptoms

arise

nailmag.com


Nail Diagnosis


Common Nail SignsSign Deficiency

Splitting, fraying,

chipping, peeling, easily

broken

Vitamin A, C, D, calcium, protein intake and absorption, poor diet and malnutrition.

Thinning and Softening Vitamin C, B12, protein intake and absorption, poor diet and malnutrition.

Horizontal Grooving or

Ridging

Protein intake and absorption, poor diet and malnutrition.

Vertical Grooving or

Ridging

Vitamin A, calcium, iron, silica, protein intake and

absorption.

Brittleness Iron

Spooning/koilonychia Iron deficiency (Mahan and Escott-Stump, 2008)


Nutritional Deficiency


Splitting

Just.health.com

Vitamin A, C, D, calcium, protein intake and

absorption, poor diet and malnutrition.


Thinning & Softening

o Vitamin C, B12, protein intake and absorption, poor diet and malnutrition.

postitvmed.com


Horizontal Grooving or Ridging

o Protein intake and absorption, poor diet

and malnutrition. Also signs of a systemic

illness or trauma (Beaus Ridges.)


Transverse Depressions (Beau’s Ridges)

o Interruption in protein formation and nail growth

which often follows local trauma about one month

after the event

o Can occur after illness, or major metabolic condition

o May reflect poor nutritional status, febrile illness, or a

reaction to medication, Chemotherapy or other

damaging event

o May indicate malnutrition

o Exposure to cold temperatures in patients with

Raynaud's disease


Vertical Grooving or Ridging

o Vitamin A, calcium,

iron, silica, protein

intake and

absorption.

buzzle.com

handresearch.com


Vertical striations

o Alopecia areata, vitiligo, atopic dermatitis, psoriasis, splinter haemorrhage

o Subacute bacterial endocarditis

o SLE

o Rheumatoid arthritis

o Antiphospholipid syndrome

o Peptic ulcer disease

o Malignancies

o Oral contraceptive pill

o Pregnancy

o Ageing


Vertical (Longitudinal) Ridging

o Poor absorption of EFA's, Vitamins and Minerals (Iron,

Silica); Thyroid dysfunction; Kidney failure

o May indicate a tendency to arthritis

o Occur in some patients with rheumatoid arthritis,

peripheral vascular disease, lichen planus, or Darier's

disease

o Longitudinal red/white striations invariably occur with

Darier's disease, and V-shaped notching or nicking of the

free edges of the nails are also common


Darier's Disease

o V-shaped nicking and red/white longitudinal striations of Darier's disease


Brittleness

handresearch.com


Koilonychia

o Koilonychia is associated with

chronic iron deficiency anaemia

It has even been reported in

haemochromatosis.

o It can be a normal finding in

infants and resolves within the

first 18-24 months of life.

handresearch.com


Spooning or Concavity

o Associated with iron-deficiency anaemia and Plummer-Vinson

syndrome, as a result of thinning and softening of the nail plate

o Spoon-shaped nails are a normal, physiologic occurrence in

children and tend to resolve, either with treatment or with

ageing

o Indicate deficiency of iron, protein (especially sulphur

containing amino acids)

o Possible precursor to haemochromatosis

o Raynaud's disease; SLE


Spooning or Concavity


Brief case scenario:

o A client presents with digestive problems (cramping and bloating after meals)

and a largely takeaway vegetarian based diet. Additionally she has heavy

menstrual bleeding and has been feeling very fatigued for several months.

o What appearance would you expect her nails to have? What deficiency is it

most likely indicative of? How long might she have had this deficiency?


Pitting (punctate depressions)

o Punctate depressions in the nail plate, sometimes with

yellow or brown ‘oil’ spots

o The pits represent abnormal keratinisation in the nail

matrix

o Indication of connective tissue disorders

o Most commonly occurs with psoriasis, less so with

alopecia areata and eczema

o Reiter's syndrome

o Sarcoidosis

o Pemphigus

o Alopecia areata (Fawcett et al, 2004)


Pitting

(punctate depressions)


Brief case scenario:

A 75 year old client presents with long term reflux and arthritis that she

manages with pain killers, the most recent of which is Panadol-Osteo which she

finds helpful. On review, her diet is very refined and deficient of many nutrients,

especially essential fatty acids.

What would you anticipate her nails might be like? What kind of nail signs?

What nutrients or dietary changes would you suggest to improve her nails (and

her overall health)?


Nail signs indicative of Nutritional Deficiency

Sign Deficiency

White Spots Vitamin A, calcium, zinc (Bakan,

1990)

Paleness or

whitening

Iron, B12, Folic Acid, protein intake

and absorption.

Yellowing Vitamin E

Darkening or

blackening

Vitamin B12

Pitted red-brown

spot

Vitamin C


White Spots

o Vitamin A,

o calcium, zinc o (Bakan 1990)

nailsmag.com

examiner.com


Paleness or whitening

o Iron, B12, Folic

Acid, protein

intake and

absorption.

www.tti.library.tcu.edu.tw/DERMATOLOGY/na/na0023f.htm

www.tti.library.tcu.edu.tw/DERMATOLOGY/na/na0025f.htm


White Nail

o White, Crumbly and Soft

o May be fungal infection

o White with red at the tips

o Cirrhosis of the liver;

o Kidney disorders

o Anaemia

o Fungal infection

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/terry2.jpg

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/terry2.jpg

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/terry.jpg

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/terry.jpg


White Nailo Unusual whitening of the nail plate where the lunula may be

obliterated, may result from:

o Liver disease (Cirrhosis).

o Kidney dysfunction

o Diabetes mellitus

o Heart Disease

o Hyperthyroidism

o Anaemia

o Arsenic poisoning

o Renal failure

o Pneumonia

o Hypo-albuminaemia

Malnutrition


Muehrcke's Lines

(pairs of transverse white lines)o Interruption of pigmentation

(Specific for hypo-

albuminaemia)

o May disappear when

protein levels normalise

o May also indicate Kidney

disease

o Liver disease

o Malnutrition

o Chemotherapy

(Fawcett et al, 2004)


Mees' lines (Aldrich-Mees' lines)

o Single transverse white line

o Heavy metal poisoning

o Sign of ‘interrupted’ metabolic

activity;

o Hodgkin's disease

o Congestive Heart Failure

o Malaria

o Chemotherapy

o Carbon monoxide poisoning

o Renal failure. (Fawcett et al, 2004)

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/muehrcke.jpg

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/muehrcke.jpg


Yellowing

o Usually associated with

Lymphedema & Respiratory

tract disorders (Tosti & Piraccini, 2000)

o Pulmonary disorders (e.g.

Bronchiectasis, Tuberculosis,

Pleural Effusion)

o Lymphatic dysfunction

(Lymphoedema, especially of

the ankles)

o Rheumatoid arthritis

o Renal disease (Nephrotic

syndrome)


Yellowing

o Immuno-deficiency

o Vitamin E deficiency

o Thyroiditis

o Raynaud's disease

o Liver dysfunction

o Fungal infection

o Psoriasis


Yellow Tips

o Liver problems

o Melanoma

o Digestive disturbances

o Smoker

o Tetracycline.

o Rx = Oral Vitamin E at doses 600-1200 IU daily for

6-12mths may induce complete clearing of nail

changes (Tosti & Piraccini, 2000)


Green

o Pseudomonas

o Candidiasis

o Bacillus infection

o Localized fungal infection

o Allergies to cleaning agent

o Serious emphysema

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/paron-ps.jpg

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/paron-ps.jpg


Pitted red-brown spot

o Pitted red-brown spots

o May indicate psoriasis

o Deficiency of folic acid, protein and/or Vitamin C

www.medscape.com.

Red Nail

o Red Bands at the Tips(Terry’s Nails)

o Liver disease

o Renal disease

o Redness of the lunula

o Excess of RBC

o Heart disease

o Collagen vascular disease

o Haematological malignancy

o Tetracycline therapy

www.medscape.com


Grey

o Arthritis

o Oedema

o Malnutrition

o Post-operative effects

o Glaucoma

o Cardio-pulmonary

disease www.health-network.co.uk


Blue or Blue-Grey Nails

o Blue or Deep Blue:

o Indicates poor oxygenation of the blood

o Lupus erythematosus/ RA

o Liver disease (Hepatitis)

o Kidney disease

o Copper or silver poisoning

o Anaemia (Decreased haemoglobin)

o Increased inflammation

o Cholesterol Fawcett et al, 2004)


Blue, Purple, Black Nails

o Blue, Purple & Black

o Usually due to trauma

o May be a sign of vitamin B12 deficiency

o Oxygen deprivation

o Circulatory problems

o Congenital disorder

o Blue or ‘azure’ lunula

o May indicate Wilson’s Disease (Hepatolenticular degeneration)

o Quinacrine therapy

o Pulmonary disease

o Silver poisoning


Darkening Browno Browning

o Excessive fluoride ingestion; Arsenic or copper poisoning;

Fungal infection

o Brown discoloration that has spread to the surrounding

tissue could indicate gastro-intestinal polyps or malignant

melanoma

o Pitted brown spots or splits fingernail tips

o May indicate psoriasis

o Brown Spots are typically a sign of infection (Fungal)

o Dark nails that are flat and/or thin

o Indicate vitamin B(12) deficiency

o Dark pigment on distal nail:Drug-induced (Phenothiazines)


Darkening or blackening

o Vitamin B12

schaltzie-speaks.hubpages.com


Darkening Black

o Blackening or Darkening

o Excessive fluoride ingestion

o Heavy metal poisoning (Silver)

o Anaemia

o B-12 deficiency

o Bacterial infection

o Kidney disease

o Adrenal gland problems

o Liver disease

o Cancer or melanoma

o Trauma


Darkening Black

o Black Spots

o Typically a sign of infection

o Any black discolouration that has spread to the surrounding tissue could indicate gastro-intestinal polyps or malignant melanoma

www.medscape.com


Longitudinal Melanonychia

o Black discoloration of the proximal nail fold at the base of the

pigmented streak (Hutchinson's sign) is a sign for melanoma

o Longitudinal melanonychia in one nail without an obvious

explanation warrants a biopsy of the nail matrix. Melanoma of

the nail unit has a poor prognosis


Half White & Half Brown Nails

o Renal disease

o Increased melanin

production


http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/half.jpg

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/half.jpg


Onychomycosis (Tinea unguium)

o A fungal or yeast infection of the nail, usually caused by Tinea rubrum,

T. mentagrophytes, or Candida albicans;

o Most common nail disorder!

o Predisposing factors for infection include immune problems, heat,

moisture, trauma, diabetes mellitus, and tinea pedis

o Affected nails are dystrophic and hyperkeratotic (thickened), often

with yellow-brown discoloration


Onychomycosis (Tinea unguium)

o Treatment can be symptomatic, frequently with the aid of a podiatrist for

toenail onychomycosis. If warranted, systemic treatment involves the use of

either terbinafine or itraconazole (Success with either agent is less than 50%,

and recurrences are common)

http://www.dermnetnz.org/fungal/candida.html

SOURCE: CDC/Dr. Edwin P. Ewing, Jr.


Nail Plate Separation (Onycholysis)

o It can be caused by any local problem, such as periungual

warts or onychomycosis

o In patients with hyperthyroidism, onycholysis is known as

‘Plummer's nails’

o Hyperthyroidism also can cause brown discoloration of the

nail plate

o Psoriasis

o In the absence of trauma or psoriasis, onycholysis should

prompt a search for symptoms of hyperthyroidism

o Anaemia


Nail Plate Separation (Onycholysis)

o Fungal, Yeast or Bacterial Infections

o Medications, Drugs (e.g. Tetracycline)

o Chemotherapy

o Raynaud’s disease

o SLE

o Thyrotoxicosis

o Hyperthyroidism

o Amyloidosis

o Sarcoidosis and other connective tissue disorders


Nail Plate Separation

o Onycholysis may accompany psoriasis, when the

distal portion of the nail matrix is affected


Psoriasiso Characterised by raw, scaly skin and is sometimes

confused with eczema

o When it attacks the nail plate, it will leave it pitted, dry,

and it will often crumble. The plate may separate from the

nail bed and may also appear red, orange or brown, with

red spots in the lunula

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/pits-ps.jpg

http://dermnetnz.org/common/image.php?path=/hair-nails-sweat/img/pits-ps.jpg


Thickened Nails

o Unusually thick nails: may be the result of internal disorders

o May indicate a weakening of the vascular system, with

circulatory problems

o Fungal infections

o Heredity

o Mild, persistent trauma to the nail


Nail Hematoma

o The result of trauma to the nail

plate, such as trapping your

finger in the car door or hitting

the fingernail with a hammer


Pterygium of Nail

o An inward advance of skin over the nail plate

o Usually the result of trauma to the matrix due to a surgical procedure, or by a

deep cut to the nail plate

o Pterygium results in the loss of the nail plate due to the development of scar

tissue


In-grown Toenail (Onychogryposis)

o Claw-type nails, characterised by a thickened nail plate and

often the result of trauma

o Often require surgical intervention to relieve the pain


Clubbing

o Clubbing is one example of a nail manifestation of systemic disease

and was first described by Hippocrates in the fifth century B.C., and

may indicate

o Pulmonary Disease, including Bronchiectasis, Bronchitis, Lung

abscess, Empyema, Pulmonary Fibrosis, Cystic Fibrosis,

Asbestosis, Malignancy

o Cirrhosis of the Liver

o Cardiac Disease, such as Congenital Heart Disease, Endocarditis,

Atrioventricular malformations, Fistulas

o GIT Diseases, such as: Coeliac Disease, Ulcerative Colitis or

Inflammatory Bowel Disease

o Hyperthyroidism


Clubbing

o The finding of clubbing without obvious associated disease

should prompt a search for bronchial or cardiac disease


Splinter Haemorrhage

o This sign often follows

trauma to the nail

o If no trauma, look for

bacterial endocarditis

o They may resolve,

recur, or persist


o Possible indication of

vitamin C deficiency


Verruca Vulgaris (Warts)

o Warts, or verruca vulgaris, are an infection of the proximal and

lateral nail folds

o The human papilloma virus (HPV), types 1, 2, and 4 are primarily

responsible

o Because of the location, these warts are particularly difficult to

treat, especially if they extend subungually

o Subungual warts may cause deformity or discoloration of the nail

plate

o Affected patients are often

‘nail biters’


Paronychia Infection

o Can be caused by a

number of bacteria, fungi,

yeast and viruses

o Usually staphylococcus,

streptococcus or candidiasis

infection


Acute Paronychia

o Inflammation of the proximal and lateral nail folds

characterised by erythema, oedema, and pain

o Purulent drainage with compression behind the cuticle may

also occur

o Trauma is often the initial event with secondary infection with

Staphylococcus aureus

or Streptococcus pyogenes

o Treatment usually requires

compresses and an oral

anti-staphylococcal antibiotic


Chronic Paronychia

o Usually a non-infectious disease that

follows irritant or allergic contact

dermatitis of the proximal nail fold

o The cuticle is invariably absent

o Affected individuals often trim the

cuticles aggressively, or do ‘wet work’

with their hands

o Secondary infection with Candida

albicans is common

o Treatment involves aeration, and a

topical and/or oral antifungal agent


Tinea Unguis

(Ringworm of the nails)

o Fungal infection, characterised by nail thickening, deformity, and eventually

results in nail plate loss.


Squamous Cell Carcinoma (SCC)

o The most common malignancy of the nail

unit

o SCC is usually a verrucal (warty) plaque

on the lateral nail fold of the finger, and

may resemble a wart unresponsive to

traditional therapy

o SCC is associated with HPV-16 infection

and less so with trauma and radiation

o SCC of the nail unit grows

slowly and metastasis is rare


Melanonychia(vertical pigmented bands)

o Described as nail 'moles' which usually

form in the nail matrix

o Could signify malignant melanoma or

lesion


Other Nail Considerations

o Over-Sized Moons:

o Overactive thyroid;

o Genetics;

o Self-induced trauma

o No Moons:

o Under-active thyroid;

o Genetics.

www.health-boundaries.com/fingernails-linesridges

© Endeavour College of Natural Health endeavour.edu.au 67

Pre-assessment Considerations

Having gathered information about the patient (both subjective &

objective) the next step in the Naturopathic consultation process

involves analysing the various information and putting into some

form of perspective

Considerations prior to formulating an assessment of the patient

should include:

• Working hypothesis of the pattern of disturbance

• Differential diagnosis

• Rule-ins/rule-outs

• Medical Red Flags – need for referral?

• Duty of care/scope of practice


Pattern of Disturbance

Via the process of gathering patient information the Naturopath begins to

formulate an impression of what is going on with the patient (their pattern of

disturbance).

This impression is formed from information relating to the physical,

mental/psychological, emotional & “spiritual” aspects of the patient and their

health condition.

Where a biomedical practitioner aims to identify/diagnose a disease entity so

that the specific pathophysiology can be determined and treated, the

Naturopath looks to understand:

• the pattern of disturbance;

• the disturbing factors/obstacles to cure;

• the process of disease/health (is the condition acute/sub-

acute/chronic/degenerative).


Analysing the Pattern of Disturbance

• Is there a central theme or a “weak link” in the patient’s life that has

led to their current condition of health?

• What are the contributing or disturbing factors to the patient’s

condition?

• At this present time, what are the driving factors in the patient’s health

condition?

• What tissues, organs, systems are affected?

• What degenerative processes are at play currently?

• What regenerative processes are at play currently?


The Mind Map and the Timeline of Health are useful tools for

assisting to formulate an impression of the patient’s pattern of

disturbance


Tutorial

Review the Tutorial Case provided, develop a mind map and

treatment strategy for the case. Consider prioritising treatment,

differential diagnosis, further investigations needed, long and short

term goals and treatment plan options.

Apply holistic principles to your case understanding.

If time allows look at the other case studies and apply the same

considerations

Handout Cases 1, 2, 3, 4


Tutorial

Tongue and nail assessment on a partner

1. Chose a partner and conduct a Nail and Tongue assessment.

2. Explain Nail and Tongue assessment to your partner and let them know what

you plan to do.

3. In easy to understand terms describe to your partner your findings. Imagine

that they are a first appointment client.

4. Now allow your partner to give you feedback on your Nail and Tongue

assessment skills and also how they felt with your explanation and account of

your findings on their tongue and nail appearance.


Bibliography1. Yale, S. and La Valle, J.B. (2002). Food Allergies and Atopic Dermatitis. Alternative & Complementary

Therapies.

2. Sebrell, W. H. (1945). Deficiency Diseases in General Practice. Southern Medical Journal, 39 (3), pp:265-68

3. Poole, W. L. (1957). Effect of Vitamin B Complex and S-Factor on Acne Rosacea. Southern Medical Journal, 50 (2), pp:207-210

4. Majamaa, H., Miettinen, A., Laine, S., Isolauri, E. (1995) Intestinal inflammation in children with atopic eczema: faecal eosinophil cationic protein and tumour necrosis factor-a as non-invasive indicators of food allergy. Clinical & Experimental Allergy, 26 (2), pp:181-187

5. Proksch, E., Folster-Holst, R., Jensen, J. M. (2006) Skin barrier function, epidermal proliferation and differentiation in eczema. Journal of Dermatological Science, 43 pp: 159-169

6. Heath, ML., Sidbury, R. (2006) Cutaneous manifestations of nutritional deficiency, Current Opinion in Pediatrics, Vol 18 (4), pp:417-422

7. Fawcett, R. S., Linford, S., Stulberg, D. L. (2004) Nail abnormalities: clues to systemic disease, American Family Physician, 69 (6) pp: 1417-1424

8. Tosti, A., Piraccini, B. M. (2000). Treatment of Common Nail Disorders, Dermatologic Clinics. 18 (2)

9. Field, A. E., Speechley, J. A., Rugman F. R., Varga, E., Tyldesley, WR. (1995). Oral signs and symptoms in patients with undiagnosed vitamin B12 deficiency, Journal of Oral Pathology and Medicine, 24, p:468-470

10. Marks, R and Simons, M. J. (1979). Geographic tongue – a manifestation of atopy. British Journal of

Dermatology, 101, pp:159-162

11. Rogers, RS and Bruce, A. J. (2004). The tongue in clinical diagnosis, European Academy of dermatology

and Venerology, 18, pp:254-259


Bibliography12. Jansen, A.J. and Bailey, K.V. (1977). The early detection of childhood malnutrition in the south pacific, J

Trop Pediatr, Vol 23, pp: 125-137

13. Femiano, F. (2001). Geographic tongue (migrant glossitis) and psoriasis, Minerva Stomatol, Vol 50 (6)

pp:213-7

14. Smith, C and Song, W. (1996). Comparative nutrition of pantothenic acid, The Journal of Nutritional

Biochemistry, Vol 7 (6), pp:312-21

15. Areekul, S., Panatampon, P. and Doungbarn, J. (1977.) Vitamin B12 and vitamin B12 binding proteins in

liver diseases, Southeast Asian J Trop Med Public Health, Vol 8 (3) pp:322-8

16. Barthelemy, H., Chouvet, B., Cambazard, F. (1986) Skin and mucosal manifestations in vitamin

deficiency, J Am Acad Dermatology, Vol 15 (6) pp:1263-74

17. Predniville, J.S and Manfredi, L.N. (1992). Skin signs of nutritional disorders, Seminars in Dermatology,

11 (1) pp: 88-97

18. JAE-YOUNG UM et al. (2004). Association Between Iris Constitution and Apolipoprotein E Gene

Polymorphism in Hypertensives, The Journal of Alternative and complementary medicine, 10 (6)

pp: 1101-05

19. Taher, Q et al (2004) Nutritional Kiolonychia in 32 Iraqi subjects, Annual Saudi Medicine, Vol 25 (2) pp:

154-157

20. just.health.com

21. www.medscape.com

22. www.health-boundaries.com/fingernails-linesridges

23. Tully, A.S, Trayes, K.P, Studdiford, J. (2012). American Family Physician, Evaluation of nail abnormalities.

85(8):779-87. https://www.ncbi.nlm.nih.gov/pubmed/22534387


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